
Class 
Book 



COPYRIGHT DEPOSIT 



NUTRITION AND GROWTH 
IN CHILDREN 



4 




A FULL FACE DOES NOT ALWAYS INDICATE A WELL NOURISHED BODY 



Herbert, aged six and one-half years, is more than two vears retarded 
in growth. His round shoulders, protruding shoulder blades, prominent 
abdomen, flabby muscles, and fatigue posture are all siuns of malnu- 
trition, but his round face and regular features make him look well 
nourished when dressed. Defects: underweight 16 per cent (8 lb.); 
nasopharyngeal obstruction; carious teeth (two) ; spinal 
curvature; otitis media; fatigue posture. 



NUTRITION AND GROWTH 
IN CHILDREN 



BY 
WILLIAM R. P. EMERSON, A.B., M.U 

PROFESSOR OF PEDIATRICS, TUFTS COLLEGE MEDICAL SCHOOL ; 
PRESIDENT, NUTRITION CLINICS FOR DELICATE CHILDREN, 
INCORPORATED J MEDICAL ADVISER, ELIZABETH MCCOR- 
MICK MEMORIAL FUND, CHICAGO; VISITING PHYSICIAN 
(IN CHARGE OF NUTRITION CLINIC), CHILDREN'S 
OUT-PATIENT DEPARTMENT, MASSACHUSETTS GEN- 
ERAL HOSPITAL, BOSTON 




ILLUSTRATED 



D. APPLETON AND COMPANY 

NEW YORK LONDON 

1922 






V 



COPYEIGHT, 1922, BY 

D. APPLETON AND COMPANY . 



Copyright, 1919, 1920, 1921, by 
"Woman's Home Companion" 

PRINTED IN THE UNITED STATES OF AMERICA 



MAR -2 1922 



©CI.A654785 






TO 
MY MOTHER 



PREFACE 

In 1908, while in charge of the Children's Out- 
Patient Clinic in the Boston Dispensary, I became 
interested in a number of undernourished children 
who kept coming to the dispensary week after week 
and month after month, passing from one department 
to another without receiving help. Their records 
showed long histories and repeated examinations, yet 
the most frequent diagnoses were "Debility" or "No 
disease.'' From the medical standpoint there was 
nothing the matter with them, but from the point of 
view of physical fitness there was everything the 
matter with them. 

I formed a group or class of 12 of these children, 
and had them report once a week with the idea of 
studying them for the whole 24-hour period to dis- 
cover if possible the real cause of their poor physical 
condition. In order to visualize their progress, as 
well as to arouse interest, I made charts showing the 
actual weight of the children from week to week, 
with a comparative line representing what their 
weight should be. The mothers were invited to at- 
tend the class and consulted as to the possible cause 
of failure to gain. Advice was then given on any 
point that seemed to promise better results. 

Although the majority of the group showed some 
signs of improvement, and an occasional child would 
gain sufficiently to come up to the average standard, 

vii 



PREFACE 

many of the children made little or no progress, and 
after months of effort their charts showed lower rela- 
tive weights than at the start. 

So far as I know, this was the first nutrition class 
ever organized. 

The net results of this experiment were the ideas 
of class organization, the importance of considering 
the child's entire program, the advantage of visualiz- 
ing his physical condition by means of the weight 
chart, and, perhaps most important of all, the chal- 
lenge that came to me from those patient and per- 
sistent mothers who were ready to do all that I asked, 
even when rewarded by only slight evidence of prog- 
ress. Such was the interest of the children and their 
mothers that I still have hundreds of charts from 
these early years which register regular attendance 
for periods as long as 40 weeks without a relative 
gain of a single pound. 

Looking back through thirteen years' study of this 
problem, I find the following ideas to have been con- 
sidered in turn as primary causes of malnutrition, 
only to be discarded or relegated to a position of sec- 
ondary importance, one after the other: 

1. Poverty and insufficient food supply 

2. Improperly cooked food and consequent indigestion 

3. Bad air 

4. Heredity 

5. Syphilis 

6. Tuberculosis 

7. Self-abuse 

The study of each of these theories made some im- 
portant contribution to the ultimate development of 

viii 



PREFACE 

our present nutrition program, but the outcome was 
in every case different from what I had expected, and 
I was obliged to enter upon a new investigation. 

At the time when I began my studies, malnutrition 
was almost invariably considered to be a problem of 
poverty and food, and my approach to it was from 
this standpoint. At the first meeting of the class of 
mothers and children referred to, I supposed it would 
be necessary to see that the families were supplied 
with sufficient food and taught to prepare it properly. 
I had even gone so far as to purchase a cook book and 
study it, so that I could, if necessary, teach the 
mothers how to prepare food. 

It soon became clear, however, that although pov- 
erty is a contributing factor, it is not the funda- 
mental cause of malnutrition. Later investigations 
show an even higher percentage among the well-to-do 
and the rich than among the children of the poor. 
With few exceptions, the families concerned in this 
first study were found to have sufficient food for good 
nourishment, but the malnourished child had either 
omitted certain essential foods from his diet or else 
had formed bad food habits. 

Ideal family life requires provision for privacy, 
wholesome recreation, and much else that is not easy 
to secure. It is not merely a question of the bare 
necessities, but of conveniences and comforts as well. 
Nevertheless, my experience in the poorest sections of 
our cities, with children both in their own homes and 
in charity clinics, shows that the essentials of health 
are attainable in the home of practically every family. 
More recent studies indicate that many families 
among the poor consume too large a proportion of 

ix 



PREFACE 

the more expensive foods, and it is frequently pos- 
sible to teach a mother how to care better for her 
family on less money than she has been accustomed 
to spend for food. 

The matter of cooking in its bearing on the child's 
nutrition also retired to a secondary position as I 
found that the city mother does comparatively little 
home cooking. Hot bread and deep frying, which 
produce much of the indigestion found in more re- 
mote sections of the country, are not customary fea- 
tures of the diet of poor families in the cities. 
Standardized bread and milk have taken the control 
of these fundamental foods away from the home, and, 
with the abundant supply of good cereals, a large 
part of the usual dietaries is thus established on a 
high plane. Food is important, but the difficulty is 
usually in the food habits of the individual rather 
than in the quantity available or in the mode of 
preparation. 

At this time it began to be apparent that the fun- 
damental causes of malnutrition are more individual 
than had been supposed. I had feared that in many 
homes a number of children would be found suffer- 
ing from this condition, but it was a common experi- 
ence to find one child underweight with his sisters or 
brothers up to the normal standard or even over- 
weight. It was not until 1913, after I had been giv- 
ing my main energies to the problem for five years, 
that a family appeared in which as many as three 
children were malnourished, and this family was in 
fairly comfortable circumstances. 

From this study of the child's nutrition on an in- 
dividual basis came an appreciation of two new fac- 

x 



PREFACE 

tors of vital importance, namely, measured feeding 
and proper food habits. Prof. Irving Fisher's notable 
article on 100-calory portions, with the reports of 
the United States Department of Agriculture, made 
it possible to work out tables to determine the actual 
food consumption of the individual. Measured feed- 
ing and careful observation of the food habits of the 
child are now regular features of our nutrition pro- 
gram. 

The next subject specially considered was bad air, 
particularly in relation to sleeping conditions. This 
was in 1911, when our first clinic was established at 
the Berkeley Infirmary. The Berkeley window tent 
was used as a means by which a child could gain the 
benefits of sleeping in the open air while remaining 
in his own home. 

In order to install these tents it was necessary to 
go into the homes and work out new sleeping ar- 
rangements. This afforded an opportunity for con- 
tact with the family in a natural way. I have always 
insisted that no one has a right to cross the threshold 
of a home except on the invitation of the family, and 
that the privilege should not be abused by an attempt 
to discover the skeleton in the closet. 

This step in the investigation gave a glimpse into 
the significance of home organization and control, 
although the particular line of attack from which it 
developed, the consideration of bad air, proved no 
more than poverty or badly prepared food to be a 
fundamental cause of malnutrition. The children 
did better under the improved sleeping conditions, 
but the central problem was still unsolved. 

Heredity as an explanation of malnutrition is still 
xi 



PREFACE 

a favorite hypothesis. Most undernourished children, 
however, are born of normal weight, and continue to 
be well and strong through the period of infancy. 
It is only when they come to the pre-school or school 
age that malnutrition appears. This may follow an 
acute illness, such as measles or whooping cough, or 
it may be a gradual loss in weight which is taken for 
granted in the growing child. Here again it is sig- 
nificant that where one child may be malnourished, 
other members of the family may be in good health. 

When Wassermann tests were applied to groups of 
malnourished children, I found the indication of 
hereditary syphilis to be somewhat greater than 
among other groups, but in no study did it amount 
to more than four or five per cent, and consequently 
it cannot explain the widespread malnutrition. 

Similarly, the proportion of positive von Pirquet 
tests was about the same as that found among chil- 
dren not suffering from malnutrition. Those children 
whom we thought might be tubercular gained in 
weight as fast as the others when the real cause of 
their underweight was finally determined. 

There is a general belief that self -abuse is a cause 
to be reckoned with in dealing with a debilitated con- 
dition, but I have not found a single case in which 
malnutrition could be traced to this source. This 
experience coincides with that of the neurologists, 
who rarely, if ever, find self -abuse a cause of either 
mental derangement or poor physical condition. It 
is a common symptom of mental deficiency, but in 
every case of normal mentality in my experience the 
practice has been due to local irritation caused by a 
pyelitis, cystitis, or other inflammatory condition. 

xii 



PREFACE 

It was somewhat disconcerting after a thorough 
study of these usually assigned causes of malnutri- 
tion to find the problem still unsolved. Difficult as 
it was to disabuse my mind of these ideas, I decided 
to study the children as I found them, to utilize every 
possible means, medical, physical, social or psycho- 
logical, to get each child well, and to seek with open 
mind the cause of his malnutrition. This point of 
view led to a new outlook and to an entire recon- 
struction of values. 

Medical social service was at this time in a state 
of agitation and unrest, and it was difficult to make 
progress because the trained worker, like the physi- 
cian, was prepossessed with ideas which experience 
had shown me were not valid. During the earlier 
years of my experiments I was fortunate in having 
the assistance of Miss Ruth L. Greeley, a faithful and 
devoted volunteer worker. Since 1912 Miss Mabel 
Skilton has been associated with me in this work, and 
her untiring interest and personal work with both 
mother and child have been of the greatest value in 
the development of the nutrition class. 

The results of earlier studies which continued ex- 
perience had by this time brought into clearer defini- 
tion as of vital importance were home control, food 
habits, and health habits. Two new factors now 
claimed attention, namely, physical defects, particu- 
larly obstructions to breathing, and overfatigue. 
These five factors form the basis of our present nutri- 
tion program and have proved to be fundamental 
ideas to be considered in the care of the growing 
child. 

As these ideas were formulated into a definite nutri- 
-s xiii 



PREFACE 

tion program, our work attracted attention in other 
cities. Among the visitors to our clinics in 1916 was 
Mr. Frank A. Manny, representing the New York 
Association for Improving the Condition of the Poor. 
This society, after an honorable record of three- 
quarters of a century spent in wrestling with the 
problems of poverty and disease, had undertaken 
under Mr. Manny's direction a study of the causes 
and treatment of malnutrition. Arrangements were 
made for presenting our program at the Academy of 
Medicine, and the workers in a number of child- 
helping organizations cooperating with Mr. Manny 
came to Boston for advice and training. Clinics and 
classes were established in this connection at Bellevue 
Hospital, Cornell Medical School, Bowling Green 
Neighborhood Association, Post-Graduate Hospital, 
and with a number of the activities that later crys- 
tallized into various national organizations for child 
health. 

I had long felt that the proper place to deal ade- 
quately with malnutrition was in the public school, 
where it would be possible to reach practically all the 
children in the community. I was glad, therefore, to 
accept an invitation from the Bureau of Educational 
Experiments to supervise an experimental study on 
the East Side of New York City. 

"Work was accordingly undertaken in 1918 in Pub- 
lic School 64 and carried on for a period of 19 weeks. 
This school had a very conservative program, and in 
adjusting our nutrition classes to the school schedule 
many compromises were necessary. Although it was 
a war year and the cost of food seemed to offer ex- 
traordinary difficulties, it was nevertheless demon- 

xiv 



PREFACE 

strated in this experiment that, with slight modifica- 
tion of their day's program, the malnourished chil- 
dren could be made well in their own homes. The 
gains made varied from 100 to 200 per cent of the 
expected rate of growth for normal children. 

To meet the growing demands from various sections 
of the country, a national organization, Nutrition 
Clinics for Delicate Children, Incorporated, was 
formed in 1919. The requests for special training 
have led to the holding of institutes twice a year in 
both Boston and Chicago, in which physicians, re- 
search students, nurses, social workers, dietitians, 
charity workers, teachers and other experienced per- 
sons have been given intensive instruction and dem- 
onstrations of nutrition clinics and classes. 

Clinics and classes have been established in the 
meantime at the Massachusetts General Hospital, the 
Little Wanderers' Home, various neighborhood set- 
tlements, the Farm Home of the Boston Fathers and 
Mothers Club, and in connection with the Boston Tu- 
berculosis Association. Each of these organizations 
represents a distinct type of need, and in each we 
have been able to demonstrate that malnourished 
children can be made well by means of a simple nu- 
trition program. 

Through an address delivered in Washington at the 
International Child Welfare Conference in May, 
1919, our work came to the attention of Mrs. Ira 
Couch Wood, director of the Elizabeth McCormick 
Memorial Fund, Chicago. After a thorough test our 
nutrition program has since been adopted by Mrs. 
Wood as the basis of the work of that organization, 
which reaches not only the home city and state, but 

xv 



PREFACE 

also influences child-welfare work throughout the 
West. The office of the Fund has now become the 
Western headquarters of our society, and under its 
auspices five institutes have already been held, in- 
cluding in their membership representatives of nearly 
all the Western states. 

The first comprehensive community program de- 
veloped in 1919 in Walpole, Massachusetts, where the 
school authorities sought our cooperation in eliminat- 
ing malnutrition. All the children in the public 
schools of that town have been weighed and meas- 
ured, and nutrition classes have been formed for those 
found to be seven or more per cent underweight. 

An institute held in Atlanta under the auspices of 
the American Red Cross in May, 1920, was attended 
by 50 members, including representatives of the 
United States Department of Agriculture from prac- 
tically all the Southern states. Summer sessions 
were held in June, 1920 and 1921, at the School of 
Education in Cleveland, where an affiliated organiza- 
tion carries on the work. In November, 1920, the 
Tuberculosis Association acting with other child-help- 
ing organizations united in an institute of over a hun- 
dred members, including 22 physicians, at Rochester, 
New York. 

More recently a largely attended institute has been 
held at Grand Rapids, Michigan, under the auspices 
of a child-health association organized for the pur- 
pose, and a state- wide movement has been inaugurated 
in New Hampshire after an institute that was at- 
tended by representatives from 62 cities and towns. 
The nutrition movement has been extended to an older 

xvi 



PREFACE 

group in this state by the inauguration of classes for 
the students at Dartmouth College. 

Public addresses have been made all the way from 
New Hampshire on the east to California and the 
Hawaiian Islands on the west and as far south as 
Georgia. During the summer of 1920 two of our 
trained workers organized classes in Labrador in con- 
nection with the work of Dr. Grenfell, and their work 
was extended in 1921. 

This brief sketch of the stages through which our 
work has passed is given to show the various aspects 
of the problem presented by the malnourished child, 
who in the past has been considered neither sick nor 
well. Difficulties have been met with, and must still 
be overcome in many places before the subject re- 
ceives the attention which its importance deserves. 
Among these may be mentioned the following: 

1. Malnutrition is a very old subject, and the ideas 
and theories held about it have frequently emanated 
from men working behind desks rather than from 
those in direct contact with the children needing 
help. 

2. Nutrition work is a form of preventive medi- 
cine, all branches of which have thus far attracted 
too little attention. 

3. The laboratory field, where results can be meas- 
ured by chemical reactions and the microscope, has 
been more alluring to the research worker than clinical 
work with such a difficult and uncertain factor as the 
children themselves. 

4. On the medical side there have been practically 

xvii 



PREFACE 

no studies of the subject, and the physician has been 
almost as ready as the layman to accept ideas put 
forward without foundation or justification. As a 
result little help has come from the quarter that 
ought to aid the most. Progress will be delayed until 
fundamental work in nutrition is an established part 
of the training of the physician. At present the field 
is almost untouched in either medical school or hos- 
pital. 

5. Although the problem is fundamentally medical, 
it is also largely educational, touching the most inti- 
mate human experiences — the habits and prejudices 
of a lifetime in both parent and child. 

6. The malnourished child is not considered sick 
as long as he is able to be on his feet. Even to the 
average physician there is nothing urgent in his need. 
In the schools there are so many of these unfortunate 
children, from one-fourth to one-third of all, that the 
teachers have become accustomed to attempting to 
force them through the grades in order to maintain 
the school's supposed efficiency, whereas in reality 
their condition is a constant occasion for lowering 
standards. 

7. The program of nutrition clinics and classes 
meets the opposition of many organizations that do 
not willingly relinquish the ideas upon which their 
work is founded. 

The spread of these ideas would necessarily have 
been much slower had it not been for the startling 
revelations of the selective service draft. The report 
of the Surgeon-General of the Army, which showed 
barely 50 per cent of our young men physically fit 

xviii 



_ 



PREFACE 

for service in the first line, was a shock to medical 
men, economists, educators, and the general public. 
The fact that this condition was largely due to de- 
fects and habits that are remediable in childhood has 
focussed attention upon the problem of these early 
years. It is in the hope that a wider knowledge of 
our nutrition program may help to correct this con- 
dition that this book on Nutrition and Growth in 
Children is written. 

I wish to express my deep personal appreciation of 
the helpfulness of Mr. Frank A. Manny in preparing 
these pages, especially the statistical work; of Mrs. 
Katharine Maynard in rearranging and revising the 
text and in making the glossary and index; and of 
Miss Marion Dickson in the making of charts. I wish 
also to acknowledge again the assistance received from 
Miss Mabel Skilton in working out these nutrition 
problems, and the cooperation of many others 
throughout the country who have borne an impor- 
tant part in extending the work. 

William R. P. Emerson 



xix 



CONTENTS 



Preface 



PAGE 

vii 



PART I 
THE DIAGNOSIS OF MALNUTRITION 



I. 


Malnutrition and Growth 


. 


3 


II. 


How to Identify the Malnourishee 


► 




Child 


12 




Weight Standards 






12 




Weight Tables . 






13 




The Malnourished 






14 




Borderline Cases 






16 




Ideal Weight 






17 




The Overweight . 






19 




How to Weigh and Measure . 


19 


III. 


The Case History 


21 




The Family History 


22 




Birth and Infancy 


22 




Previous Diseases ... 


23 




General Health and Habits 


23 




Present Symptoms 


24 


IV. 


The Physical-Growth Examination 


25 




Physical Signs 


28 




Naso-Pharyngeal Obstruction . 


29 




Teeth Defects ..... 


. 31 




Medical Defects ..... 


. 32 




Defects at Various Ages . 


. 34 




The Examination Form 


. 35 




"Before" and "After" Pictures 


. 41 


V. 


The Mental Examinat 


ion 


• • • 


. 43 



XXI 



CONTENTS 










CHAPTER PAGES 

VI. The Social Examination . . . .51 


The 48-hour Record .... 

Overfatigue 

Home Conditions .... 

Food Habits 

Health Habits 

The New Program .... 

Foster Homes 

Summary of a Social Investigation 


52 
54 
55 
55 
. 55 
56 
57 
58 



PART II 
MALNUTRITION AND THE HOME 



VII. 



VHI. 



IX. 



The Essentials of Health 
The Home . 
The School . ... 
Medical Care 
The Child's Own Interest . 



Home Control 

Training for Health . 
Winning the Child's Confidence 
The Correction of Bad Sex Habits 
Selfishness in Parents and Children 
The Influence of Suggestion and Compe 

tition 

Punishment Should be Constructiv 
Responsibility of the Parents . 

Overfatigue 

Fatigue and Overfatigue . 
Causes of Overfatigue 
Rest and Sleep .... 
The Strain of School Life 
Outside Studies and Clubs 



Measured Feeding ... 
Food Values .... 
A Food Exhibit .... 
A Diet Record .... 
How to Make Changes in the Diet 
An Aid to Diagnosis . 
xxii 



CHArTEB 



XL 



XII. 



XIII. 



XIV. 



CONTENTS 

PAGE 

Increasing the 24-Hour Amount . . 97 

The Amount of Food Needed ... 98 

Diet and Food Habits .... 107 

The Balanced Diet 109 

Essential Foods 110 

Sweets 114 

Liquids and Mastication .... 114 

Fast Eating 116 

The Family Table 116 

Loss of Appetite, Its Cause and Its Cure 117 

Food Aversions 119 

Health Habits 123 

Fresh Air 124 

Drugs Unnecessary 128 

Care of the Teeth 130 

The Right Kind of Clothing ... 130 

Bathing 132 

Habits and Health 133 

Exercise and Recreation .... 134 

Training in Play 134 

The Need of Moderation . . . .135 

Corrective Exercises 137 

Indoor Amusements 138 

A Health Program for Summer . . 138 

The Benefits of the Summer Camp . 140 

Athletics for the Older Boy and Girl . 142 

Health in Industry and Business . . 144 

The Pre-School Child .... 146 



XV. The Overweight Child . . . . 

What Constitutes Overweight? 

Comparison of Overweight and Under- 
weight Children with Respect to 
Physical Defects 

Danger of Overweight 

The Cause of Overweight . 

The Remedy for Overweight 

Influence of Heredity 



155 
155 



156 
158 
159 
159 
161 



XVI. Questions Commonly Asked 
xxiii 



164 



CONTENTS 



CHAPTER 

XVII. 



PART III 

NUTRITION PROGRAM FOR THE 
COMMUNITY 

PAGB 

The Nutrition Class 183 

Class Organization 184 

Class Procedure 186 

Food and Rest 188 

Results Secured ...... 189 

Summary 191 



XVIII. 



The Nutrition Worker .... 193 

The Nutrition Worker and the Physician 195 

Visitors 196 

A Social Diagnostician .... 197 

Home Visits 198 

Family Types 201 

Interest in Children 204 

The Appeal of Nutrition Work . . 205 

XIX. The Physician and the Nutrition Class 207 



XX. Report of a Class Meeting 

XXI. The Nutrition or Diagnostic Clinic 

XXII. Malnutrition and the School . 
Effect of Malnutrition 
Extent of Malnutrition 
The Nutrition Program in the School 
The School Physician 
The Nutrition Clinic .... 

School Hours 

Adjustment of the Schedule . 
Adjustment of the Program . 
Health Education .... 



215 

222 

228 
228 
230 
230 
233 
233 
234 
235 
238 
239 



XXIII. School Lunches for Malnourished 

Children 241 

. 244 

. 244 

. 245 

. 246 



A Comparative Study 
Unfavorable Conditions . 
An Educational Opportunity 
Obstacles to Progress 



xxiv 



CONTENTS 

CHAPTER PAG1 

XXIV. Institutions and the Summer Camp . 249 

Foster Homes 250 

Correctional Institutions .... 252 

Summer Camps 252 

XXV. Malnutrition and the Community . . 256 

Nutrition Classes in the Schools . . 257 

Nutrition Clinics for Problem Cases . 258 

Extension Service 260 

Outline of a Community Program . 262 

XXVI. Malnutrition and Tuberculosis . . 266 

XXVII. Malnutrition and Preventive Medicine 273 

The Nutrition Program and Prevention 274 

Effect of Wrong Ideas .... 276 

Health Education and Prevention . . 279 

XXVIII. The Extent of Malnutrition and Some 

Results of Nutrition Work . . 282 



APPENDICES 

I. Tables of Weights 305 

II. Forms for Nutrition Records . . . 311 

III. Glossary 326 

IV. List of Publications of Nutrition 

Clinics for Delicate Children, In- 
corporated 331 



XXV 



ILLUSTRATIONS 

A Full Face Does Not Always Indicate a Well 

Nourished Body .... Frontispiece 

VIOUBB PAOB 

1. A Large Initial Gain 7 

2. Underweight and Underheight .... 9 

3. How to Measure facing 16 

4. A Gain of 31 Pounds in 21 Weeks ... 18 

5. Malnutrition and Obesity in the Same Family 

facing 20 

6. Complete Examination 26 

7. A Typical Malnourished Child . . facing 28 

8. Effect of Adenoid and Tonsil Operations . . 30 

9. Deformity and Malnutrition . . . facing 34 

10. Six Malnourished Girls .... facing 40 

11. Mental Retardation or Mental Deficiency facing 44 

12. Heredity is Not Usually the Cause of Malnutri- 

tion facing 52 

13. An Unhappy Home 57 

14. The Parallelogram of Forces that Safeguard the 

Child's Health 64 

15. A Difference of Five Years in Age and of Four 

Pounds in Weight .... facing 70 

16. Rest Positions facing 84 

17. Food Exhibit of Hundred-Calory Portions facing 92 

18. Insufficient Food— Thin Soup .... 94 

19. Cereal Omitted Ill 

20. Candy Habit 113 

21. Fast Eating 115 

22. Bad Air 125 

xxvii 



ILLUSTRATIONS 

FIOUR* FAGS 

23. A So-Called "Pre-Tubercular" Child . . 126-127 

24. Gain at a Girls' Camp ...... 141 

25. An Overweight Girl ..... facing 160 

26. The Case of Louise 162 

27. The Case of Dorothea, Before Treatment facing 184 

28. The Case of Dorothea 185 

29. The Case of Dorothea, After Treatment facing 186 

30. A Nutrition Class in Session . . . facing 188 

31. Nutrition Class Diploma 190 

32. The Child as an Object Lesson . . facing 210 

33. School Hours Reduced ...... 217 

34. A Case of Cardiospasm . . . . facing 224 

35. School Examinations 231 

36. School Half Day 236 

37. The Value of Lunches 243 

38. Underweight Children are Unfit for Work facing 254 

39. Continued Gain After Entering Industry . . 260 

40. An Early Chart: No Gain 288 

41. Nutrition Class and Diet Classes Compared . 289 

42. A 1918 Class at the Berkeley Infirmary, Boston 290 

43. Classes in the Francis W. Parker School, Chi- 

cago, 1920 291 

44. Group Gain at a Nutrition Camp in Grand Rap- 

ids, Michigan, 1920-21 292 



xxvm 



ILLUSTRATIONS 
FORMS 

PAQH 

I. Index Record Card 311 

II. Front and Back of White Classification Card 312 

III. Front and Back of Blue Classification Card . 313 

IV. Front and Back of Red Classification Card . 314 
V. Front and Back of Slate Classification Card . 315 

VI. Nutrition Record Card, Buff .... 316 

VII. Front and Back of Individual Weight Chart . 317 

VIII. Weight Chart for Use in Nutrition Classes . 318 

IX. Front and Back of History and Physical 

Examination Form . . . facing 320 

X. Registration and Visible Record Form . . 321 

XI. Fortnightly Report of Nutrition Class . 322, 323 

XII. Quarterly Report of Nutrition Class . 324, 325 



xxix 



I 



PART I 

THE DIAGNOSIS 
OF MALNUTRITION 



NUTRITION AND GROWTH 
IN CHILDREN 

CHAPTER I 

MALNUTRITION AND GROWTH 

The care and feeding of infants has become 
not only a science, but an art. Accurate studies 
have been made as regards food constituents, 
measured feeding, hygiene, and every detail of 
growth and development. After the age of two, 
however, the physical condition of the growing 
child receives little consideration by either 
physician or parent except in actual illness. 

Although this is a most important time for 
the child's nutrition and growth, little is done to 
make sure that he will pass through these years 
safely, and reach maturity physically and men- 
tally sound. Food and health habits are formed 
during this period, and it may be said with a 
fair degree of certainty that if good health is 
established at this time it will continue through- 
out the years of adult life. 

At least a third of all children in this country 
are underweight for their height, undernour- 

3 



NUTRITION AND GROWTH IN CHILDREN 

ished, and malnourished. This condition is 
found alike on the East Side of New York, 
among the well-to-do in such cities as Boston 
and Chicago, and in all classes of society, as 
shown in a series of investigations extending 
from Labrador to Atlanta. 

A similar situation was disclosed by the ex- 
aminations for the Army, where approximately 
the same proportion of recruits was found unfit 
for military service because of conditions 
largely due, directly or indirectly, to malnutri- 
tion. Had the causes of malnutrition been gen- 
erally understood during the childhood of these 
recruits, this physical unfitness could have been 
almost wholly prevented by the adoption of a 
simple program insuring normal healthy 
growth. 

The five chief causes of malnutrition, in the 
order of their importance, are : 

1. Physical defects, especially nasopharyngeal ob- 
structions 

2. Lack of home control 

3. Overfatigue 

4. Improper diet and faulty food habits 

5. Faulty health habits 

The requisites for good health in the growing 
child are few — good air, simple food, rest, and 
proper exercise. If the causes of malnutrition 

4 



MALNUTRITION AND GROWTH 

are removed, and these simple requisites for 
growth obtained, we have what may be called 
the essentials of health. These essentials are: 

1. The removal of physical defects 

2. Sufficient home control to insure good food and 
health habits 

3. The prevention of overfatigue 

4. Proper food at regular and sufficiently frequent 
intervals 

5. Fresh air by day and by night 

With proper planning these conditions can 
be brought about in the majority of families, 
and, as a result, the malnourished child can be 
made well in his own home. 

Why, then, has malnutrition, as a definite 
condition with definite causes and effects, been 
so generally overlooked? 

In the first place, no effective steps have been 
taken by the medical profession, by hospitals, 
or by the schools to examine children for this 
particular condition, and thus identify the mal- 
nourished group. Until the World War fo- 
cused attention upon physical unfitness, mal- 
nutrition was not generally known to be a 
serious matter. 

Moreover, there has been a general misunder- 
standing of the causes of malnutrition. Phy- 
sicians, educators, and social workers have ac- 

5 



NUTRITION AND GROWTH IN CHILDREN 

cepted, almost without question, the theory that 
this condition is due mainly to poverty and im- 
proper food. Investigation shows clearly that 
these causes, as well as many others commonly 
proposed, such as bad air, heredity, syphilis, 
and tuberculosis, are of secondary, rather than 
of primary, importance. 

A third explanation is that parents and phy- 
sicians are so accustomed to the condition that 
they pay little or no attention to it. Because 
a child is not sick in bed, and shows no acute 
symptoms, he is considered well and so treated. 
If he falls behind in his studies, pressure at 
home and school is increased. If he fails, he is 
called lazy. Thus a vicious circle is established 
that only adds to the degree of his malnutri- 
tion. It is from the ranks of such cases that the 
misfits and failures, the physical and nervous 
wrecks, who make life miserable for themselves 
and for others, are later recruited. 

Malnutrition is a clinical entity with charac- 
teristic history, definite symptoms, and patho- 
logical physical signs. The malnourished child 
is a sick child, and should be so considered. In 
the child's history it is found that malnutrition 
results from physical defects or acute illness, 
or comes on as a consequence of overfatigue 
or faulty habits in regard to food or health. 

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Figure 1. a large initial gain 

Janet D., aged six years, was 30 per cent underweight, and gained 
ir> pounds in 5 weeks. Notice the initial gain of 6 pounds in one 
week, and the gradually smaller increases as she approached aver- 
age weight. The gain continued until she was 5 per cent above the 
average for her height, clinically her normal weight. 



NUTRITION AND GROWTH IN CHILDREN 

The child becomes irritable, tires easily, lacks 
physical and mental endurance, and exhibits 
other indications of an unstable nervous condi- 
tion. 

Among the physical signs, besides under- 
weight, are lines under the eyes; anxious ex- 
pression; pallor; mouth-breathing and other in- 
dications of naso-pharyngeal obstruction; the 
anterior cervical glands are frequently en- 
larged; there may be fatigue posture, round 
shoulders, lateral curvature, flat chest, rigid 
spine, ptosis, prominent abdomen, and pronated 
or flat feet. By fatigue posture is meant an ap- 
pearance similar to the stoop that results 
from muscular weakness in old age. 

As the child approaches normal weight there 
is likewise clinical evidence of a transformation 
that is both physical and mental. There is a 
return of color and a glow of health that is un- 
mistakable. Normal reactions appear, rest- 
lessness and irritability diminish, and the child 
becomes less " finicky' ' and " nervous.' ' Par- 
ents state that the patient "has become a dif- 
ferent child." 

When physical conditions have been corrected 
in a malnourished child, and he is in the condi- 
tion which we designate as "free to gain," na- 
ture gives a strong initial impetus to his de- 

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Figure 2. underweight and underheight 

Paul L., nine years old, was 49 inches tall and weighed 47 pounds. 
He should have weighed 55 pounds, and was therefore 8 pounds, 
or 14 per cent, underweight for his height. The loss of weight 
shown during the first week occurred while he was having dental 
work done. Following this there was a steady gain until he 
reached the average weight for a hoy 49 inches tall, as shown at 
the average weight line. During these 12 weeks, however, he had 
grown in height at twice the average rate, and required 4 pounds 
additional (as shown at the dotted line) to meet the average 
weight for his new height — evidence that he had been stunted. A 
similar acceleration of growth in height accompanies gain in 
weight in nearly every instance when the child has 
been habitually underweight. 



NUTRITION AND GROWTH IN CHILDREN 

velopment. This is evidenced by a rapid ad- 
vance in weight, the rate of which is gradually 
reduced as he approaches normal condition. 
During the increase in weight there is usually 
an increase in height also. This growth in 
height is more rapid than the rate made by the 
normal child — a sudden compensation for re- 
tardation resulting from the removal of the 
causes that had been stunting growth. (See 
Figure 2.) 

When parents are awakened to the dangers 
of malnutrition their first thought is apt to be 
to take the child to some more favorable cli- 
mate, but they usually return with little evi- 
dence of progress unless the fundamental cause 
of the child's condition has been discovered and 
removed. Study and treatment of these mal- 
nourished children in nutrition classes have 
shown, almost without exception, that the real 
causes of malnutrition can be found. When 
these causes have been removed, the child re- 
sponds to the strong force in nature that makes 
for recovery, and returns to health in a remark- 
ably short period of time. 

The nutrition program adopted to secure 
these results has the following distinctive fea- 
tures, which are separately described in the suc- 
ceeding chapters: 

10 



MALNUTRITION AND GROWTH 

1. Weighing and measuring as a means of identifi- 
cation 

2. Diagnosis based on complete physical-growth, 
mental, and social examinations 

3. Removal of physical defects as a prerequisite 
for successful treatment 

4. Measured feeding (48-hour diet record) 

5. Mid-morning and mid-afternoon lunches 

6. Mid-morning and mid-afternoon rest periods 

7. Regulation of physical, mental, and social 
activities to prevent overfatigue (48-hour list of 
activities) 

8. Nutrition classes for the treatment of malnutri- 
tion 

9. Nutrition or diagnostic clinics for problem eases 



CHAPTER II 

HOW TO IDENTIFY THE MALNOURISHED CHILD 

As in the treatment and care of infants a 
steady advance in weight is one of the most re- 
liable tests of good physical condition, so also 
throughout childhood the weight curve con- 
tinues to be the surest indication of proper 
growth. Unless he is regularly weighed the 
child may fail to gain for years without its 
being noticed. For this reason all children 
should be weighed once a month. In a normal 
child loss in weight may be an early indication 
of illness ; in an undernourished child failure to 
gain means that conditions are unfavorable to 
growth and should be corrected. 

Weight Standards. — The tables in general use 
in the past have taken age as the basis on which 
to compute normal weight. But the attempt to 
apply this weight for age standard leads to 
practical difficulties at once because of the great 
variation among children of the same age. It 
also tends to discourage many who find the 
average weight for their age far beyond their 
reach. The basis of height for age is even more 

12 



IDENTIFYING THE MALNOURISHED CHILD 

perplexing because of Hie large number of 
children who are above the average height for 
their years. 

After long experimentation with these un- 
satisfactory standards, the basis of weight for 
height has proved to be an accurate measure of 
the condition of undernourished children, and 
in the many thousand cases that have come un- 
der my observation I have never found an in- 
stance in which it has proved to be impracti- 
cable. It may be stated as a physiological prin- 
ciple that a body of a certain height requires a 
certain weight to sustain it, and the most signifi- 
cant test of a child's physical condition is the 
relation between his weight and his height. 

Weight Tables. — Although the weight for 
height principle served as a remarkably satisfac- 
tory measure of the degree of malnutrition, the 
figures given in the accepted tables were soon 
found by clinical evidence to be too low. 1 After 
reaching the average weight for his height 
many a child showed by his general appear- 
ance, poor color, and nervous condition that he 
was still below his normal standard. This 
failure of the tables to agree with the other 
signs of malnutrition is explained by the fact 

1 See revised table in Appendix I, p. 305. 
13 



NUTRITION AND GROWTH IN CHILDREN 

that their averages are made up of measure- 
ments, not only of children who have attained 
normal growth, but also of those who for vari- 
ous reasons have been retarded. These tables 
are thus vitiated as normal standards, although 
recognized as valuable statistics of average de- 
velopment. It may be urged that the under- 
weight children are balanced by those who are 
overweight, but the examination of large groups 
shows that the percentage of overweight is rel- 
atively small, and is more than compensated by 
the borderline cases, while the seriously under- 
weight group comprises from one-fourth to one- 
third of the total. 

The Malnourished. — After accepting a table 
of averages, however, it was still necessary to 
determine what range of variation is compatible 
with conditions of reasonably good health and 
growth. Ten per cent underweight was first 
taken as the limit best corresponding to the 
other clinical evidence of malnutrition, but it 
soon became evident that many children in need 
of care would escape under this rule. Observa- 
tion of a large number of children indicated 
seven per cent as a more reliable minimum, and 
this is the measure now used in our nutrition 
classes. In the application of this rule I have 
never seen a child habitually seven per cent un- 

14 



IDENTIFYING THE MALNOURISHED CHILD 

derweight for his height who did not show other 
marked signs of malnutrition. 

Stress is laid upon the word "habitual" in 
this consideration of underweight, because, 
while there is often loss of weight that is the 
result of temporary conditions, in the greater 
number of instances underweight has continued 
during the major part of the growing period, 
causing the child to be not only under weight 
but under height also. In other words, the child 
is stunted, and tends to remain so unless ade- 
quate measures are taken to remedy his condi- 
tion. 

Studies made in Europe indicate that boys 
placed at an early age in military institutes, 
where they had special care, on reaching ma- 
turity attained greater height and weight than 
other male members of the same families. Men- 
del likewise reports that "in the recent war 
large groups of soldiers from certain quarters 
of London, after a short term under the more 
healthful conditions of military service, became 
so much taller and heavier that they required 
entirely new outfits." 

A small percentage of children show an ap- 
parently normal relation between weight and 
height, but nevertheless fall below the average 
in both respects. These children are also defi- 

15 



NUTRITION AND GROWTH IN CHILDREN 

nitely stunted. Under proper health conditions, 
however, a capacity for growth in both weight 
and height is shown in many cases. This group 
includes those constitutionally affected by such 
conditions as syphilis, deficient thyroid, the ef- 
fect of drugs, and children who are recovering 
from long continued illness. 

It is a common error to take it for granted 
that a child will never attain average size be- 
cause he is supposed to "take after' ' some un- 
dersized uncle or grandfather. It is easy to 
fall back upon heredity, and say, "He will never 
be a large man for he is just like my father." 
While a child may inherit certain traits from 
one ancestor, he may, in other respects, resem- 
ble another of very different characteristics. 
Furthermore, it is unfair to a child to set limits 
to his physical development until he has been 
given every possible chance to reach the best 
growth that is in him. He should be expected to 
come up to normal until every cause that might 
check his growth has been removed. 

The application of the seven per cent rule to 
any group of children will identify from 80 to 
90 per cent of those in urgent need of nutri- 
tional care. 

Borderline Cases. — There will also be found 
a considerable number of "borderline" cases 

16 



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Figure 3. how to measure 



This shows the correct position for measuring height. The child stands 
with feet together, with heels, hack, and head touching the wall. A 
hook or block resting on the top of the head and held against the wall 
Is more accurate than a ruler or flexible rod which is apt to slip 
down at the hack. A tape measure attached to the 
wall indicates the number of inches. 



IDENTIFYING THE MALNOURISHED CHILD 

who are less than seven per cent underweight, 
and who may, if neglected, easily fall further 
below their normal standard. These children 
should be brought up to proper condition as 
well, for, while they may not be strictly called 
malnourished, they are proportionately less 
able to endure special strain or sudden illness. 

Ideal Weight. — It must be recognized that 
any table made up of averages is only an ap- 
proximate standard, and every child has his 
own individual normal standard which he will 
reach under sufficiently favorable conditions. 
Many children in our nutrition classes who 
reach the average weight for their height, and 
are therefore ready to " graduate,' ' will, if kept 
in the classes for a longer period, run up to 10 
per cent above this average and then remain 
practically stationary, gaining in weight only 
in proportion to their growth in height. This 
would indicate that the best development is 
reached when a child's weight is about 10 per 
cent above the average indicated in these tables. 

During the growing period size does count. 
Although it may happen that a child who is 
small for his age shows remarkable progress in 
other respects, nevertheless any investigation 
of a large number of children will demonstrate 
that those who are taller and heavier as a rule 

17 



NUTRITION AND GROWTH IN CHILDREN 



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FIGURE 4. A GAIN OF 31 POUNDS IN 21 WEEKS 

Clayton C, aged eleven years, was 29 per cent underweight for his 
height. He was "tall for his age," 59.2 inches, which is the 
average height for a boy of fourteen. It was thought that he 
"could not grow both ways at once," but his chart shows a steady 
climb to the average weight line, which he 
reached in 21 weeks. 

have the advantage both in health and in men- 
tal development. 

18 



IDENTIFYING THE MALNOURISHED CHILD 

The Overweight. — Clinical experience indi- 
cates that when a child is 20 per cent above the 
average weight for his height, he has reached 
a point where his weight should receive atten- 
tion, and he will be better off if he does not ex- 
ceed this percentage. Children whose weight 
goes beyond this point begin to show lessened 
activity and a general lowering of health, con- 
venience, and comfort. They are to be consid- 
ered obese and in need of care. This percentage 
corresponds with the limit set by insurance com- 
panies in regard to adults. 

How to Weigh and Measure. — There should 
be scales in every home. It is important that 
the same scales be used for each weighing, be- 
cause scales vary and false records may other- 
wise be made. The child should also be weighed 
at the same hour each time, as there may be a 
variation of one or two pounds according to the 
time of day. Weight should be taken with in- 
door clothing but without shoes. 

In measuring height it is necessary to make 
sure that the measuring rod is at a right angle 
and held rigidly in place. A slight slip in posi- 
tion may make a difference of half an inch in 
the result, which means one to three pounds in 
the required weight. 

19 



NUTRITION AND GROWTH IN CHILDREN 

The use of a weight chart, 2 such as we have 
adopted for nutrition classes, will help to visual- 
ize the child's condition, and encourage his ef- 
forts to gain. The chart should have a line 
showing the average weight to be attained, and 
an actual weight line made from the weekly 
weighings. When the child's weight reaches 
the average line drawn at the time of the first 
weighing, his height should be measured again 
in order to allow for the normal rate of growth 
during the interval. The average weight for 
this new height is his present normal weight, 
and is the standard used for "graduation" 
from our nutrition classes. 

Parents too often consider the height of a 
child by itself, and assume that he is growing 
properly because he is taller than the average. 
They even boast that, "At ten he is already 
wearing a twelve-year suit!" The important 
point, however, is neither his height nor his 
weight at any particular age, but whether he has 
a body of sufficient weight to sustain his height, 
whatever his age or his height may be. As the 
child grows, every advance in inches calls for 
a corresponding advance in pounds. 

2 See Form VIII in Appendix II, p. 318. 



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CHAPTER III 

THE CASE HISTORY 

After identifying the malnourished child by- 
means of weighing and measuring, further in- 
vestigation is then required to determine the 
cause of his malnutrition. This must always 
be an individual study, and successful treat- 
ment cannot be inaugurated without a diagnosis 
as accurate as that which determines pneumo- 
nia, malaria, or other diseases. In order to find 
the cause of the child's condition, a history and 
examination form 1 has been adopted that pro- 
vides for thorough physical-growth, mental, and 
social examinations as well as for the child 's 
history in detail. 

It is of fundamental importance that both par- 
ents be present for this history taking and dur- 
ing the physical examination. They are both 
parties to the business of getting the child well, 
and it is only fair to him that they understand 
the significance of his history and of every 
defect discovered. The father and mother must 

1 See Form IX in Appendix II, facing p. 320. 
21 



NUTRITION AND GROWTH IN CHILDREN 

be depended upon faithfully to carry out all 
directions given, and therefore they must be 
made to see clearly what is necessary to bring 
about recovery. 

It may seem to them quite unnecessary to set 
forth all the details listed because they feel sure 
they remember everything that has happened to 
the child since his birth. Yet these facts, writ- 
ten down in order, present a significance that 
may easily escape the observer who considers 
them one at a time and unrelated. A careful 
and complete history is of the greatest help to 
the physician in making his diagnosis. 

The Family History. — The first group of 
questions in the form relates not to the child 
himself, but to his parents, brothers, and sis- 
ters. The answers to these questions give the 
physician important information as to the fac- 
tor of heredity and the existence in the family 
of certain diseases that may be revealed by the 
causes of death. For example, syphilis is sug- 
gested by the report of miscarriages or of still 
births. 

Birth and Infancy. — The second section has 
to do with the capital with which the child began 
life and facts as to his early development. His 
condition at birth is significant. Difficult labor 
may have caused mental defect, which may be 

22 



CASE HISTORY 

indicated by slow progress in walking or talk- 
ing. Knowledge of the child's early care not 
only further indicates his start in life, but also 
the intelligence of his parents. 

Previous Diseases. — The next division takes 
account of the more serious illnesses which the 
child has had. By the dates of their occurrence 
various complications may be traced. Attacks 
of earache should be noted, and record made of 
any bad effects that followed measles, tonsil- 
litis, whooping cough, scarlet fever, or any 
other acute infectious disease. The dates of 
previous operations should be given. 

General Health and Habits. — The food and 
health habits of the child are the basis of the 
next group of questions, and this section is of 
more importance than is commonly realized, 
because faulty habits in many small matters of 
diet and health are a common cause of malnu- 
trition. If several members of the family are 
malnourished, there is probably a common 
cause such as the use of tea and coffee, improper 
diet, or poor hygiene. Exact information is 
desirable on all these points. The physician 
will want to know, for example, not only 
whether the child eats candy, but "How much 
candy does he eat?" 

The mother should think back over the child's 
23 



NUTRITION AND GROWTH IN CHILDREN 

condition at various ages, and record the time 
when he may have been well and strong, as well 
as the circumstances that attended the begin- 
ning of his less favorable condition. 

Present Symptoms. — The physician will also 
question the parents as to their own diagnosis 
of the child's condition by such questions as, 
"Just what is the chief complaint ?" "What 
led you to bring him to me?" They may have 
a very erroneous idea of what is the matter with 
the child, but it is nevertheless desirable to hear 
their story. In this way much useful informa- 
tion may be secured, as well as an understand- 
ing of the situation with regard to home con- 
trol and discipline. Unconscious remarks by 
the parents will often throw light on the real 
cause of the child's malnutrition. 

While no history form can cover all the points 
that may be necessary to discover the cause of 
the malnutrition, yet this outline should be 
carefully completed for each child, and further 
points added as may seem to be important. 

Impressions received through the history- 
taking will direct special attention to certain 
points of the physical, mental, and social exam- 
inations that are to follow, and in this way lead 
to a more accurate diagnosis. 



CHAPTER IV 

THE PHYSICAL-GROWTH EXAMINATION 

The physical-growth examination is of great 
importance to the physician, not only for pur- 
poses of diagnosis and treatment, but also as 
an opportunity to demonstrate to the parents 
the true condition of the child. This examina- 
tion as given in our nutrition classes differs 
from the usual type not only in the complete- 
ness of the medical part of the investigation, 
but in taking account of defects affecting growth 
which are commonly overlooked. That these 
defects are significant is demonstrated by the 
fact that underweight children have an average 
of nearly six defects, while in children more 
than 20 per cent overweight the average is less 
than two. 

The examining room should be quiet, and 
have adequate light and heat. Besides the 
usual instruments, there should be an electric 
otoscope, scales for taking weight, and a meas- 
uring rod for determining height. The child's 
clothing should be removed so that his general 
condition may be observed and all defects of 

25 



NUTRITION AND GROWTH IN CHILDREN 



growth and posture noted. A man who judges 
animals knows how much would be hidden if a 
horse, for example, were inspected when cov- 
ered by a blanket. Yet this amounts to the same 



Weighing 



Measuring 



Ma I- nourished child 



Complete examination 



Mental examination . Physical growth examination Social examination 
i 1 1 1 _, i _^- 



Deration Retardation Deficiency Nuiririonalj Medical Surgical 



pro^rar 



Food 
hab.ts 



Complete diasnosis or causes of malnutrition 



Treatment 



Medial care 



Oier 



H/giene 



Prevention 
of fatigue 



Mental 
care 



Figure 6. complete examination 

Diagnosis must be based on a complete physical-growth, mental, 
and social examination. 

thing as the examination of a child when 
dressed. 

The results of a thorough physical examina- 
tion made in this manner are usually a revela- 
tion to the parents. A child with a round, at- 
tractive face passes as well nourished when an 
examination without clothing, or even in under- 
clothing would disclose serious physical defects. 

26 



PHYSICAL-GROWTH EXAMINATION 

Such an inspection by parents in the home 
would often lead to earlier discovery of a seri- 
ous condition. 

The objection is sometimes raised that the 
complete physical-growth examination takes 
more time than can be spared for it. But the 
thoroughness of the examination does away 
with the necessity for its repetition, and knowl- 
edge of the true condition of the child at the 
outset saves both time and misdirected effort. 
In one of our nutrition classes a boy who had 
been examined in the usual way and reported to 
be in normal condition was found to need care 
for the following defects : 

1. Fifteen per cent underweight for height 

2. Mouth breathing 

3. Adenoids 

4. Hypertrophic pharyngitis 

5. Diseased tonsils 

6. Enlarged cervical glands 

7. Five carious teeth 

8. Cerumen in both ears 

9. Bound shoulders 
10. Adherent prepuce 

This is one of the worst cases encountered, 
yet five per cent of the group to which he be- 
longed had 10 or more defects each. 
A defect may be either the cause or the effect 
27 



NUTRITION AND GROWTH IN CHILDREN 

of malnutrition. Those that consist of inflam- 
matory processes are usually causes, while pos- 
tural defects are usually results. 

Physical Signs. — The expression of the face 
and eyes is an important sign of malnutrition. 
The serious, drawn look with lines under the 
eyes is significant. There is usually pallor, a 
lack of the glow of health, and the hair seems 
"dead." The skin loses its normal, pink color, 
becomes rough, and is sometimes so loose that 
it can be "picked up" and separated from the 
subcutaneous tissues. The lips of the mouth 
breather are dry and crusted. 

The malnourished child's muscles are flabby. 
This is most easily tested by feeling the muscles 
of the upper arm. Similar weakness is shown 
by the very common "fatigue posture," evi- 
denced both in sitting and standing. By this 
we mean the position with the head set forward, 
round shoulders with protruding shoulder 
blades, flat chest, prominent abdomen, and pro- 
nated or flat feet. This "fatigue posture" is 
one of the most serious results of malnutrition. 
The prominent abdomen, due to relaxed walls, 
may not be evident when the child is lying flat, 
but is well marked in a standing position. The 
visceroptosis causes digestive disturbance and 
lowered vitality. 

28 




FlGUKE 7. A TYPICAL MALNOURISHED CHILD 



Alfred H., aged nine years. Notice his serious expression, mouth 
breathing, lines under the eyes, thin arms and legs, and pronated feet. 
Alfred was under observation over three years before his case was 
finally diagnosed as congenital duodenal obstruction. His defects were: 
underweight 17 per cent (9 lb.) ; naso-pharyngeal obstruction; carious 
teeth teigbt) ; fatigue posture: habit spasm; congenital duo- 
denal obstruction t bands ) with gastric dilatation. 



PHYSICAL-GROWTH EXAMINATION 

Naso- Pharyngeal Obstruction. — Obstruction 
in the nose and pharynx is perhaps the most 
important of all defects in its relation to nutri- 
tion, and its most common symptom is mouth 
breathing. As the child may keep his mouth 
closed while receiving the attention of the ex- 
aminer, this sign may pass unnoticed, but he 
should be watched when he is not aware of ob- 
servation, and if the lips are parted, the throat 
specialist should be consulted. 

Controlled observation in the nutrition class, 
with the weight chart's record of gain or loss, 
is one of the most valuable means of diagnosing 
focal infections. The failure to gain when 
other causes have been eliminated should lead 
to further examination of the naso-pharynx, and 
in doubtful cases this may reveal decisive evi- 
dence of a needed operation. 

Enlarged anterior cervical glands indicate 
diseased tonsillar tissue and a consequent ab- 
sorption of toxins. Dull ear drums also sug- 
gest a sub-acute inflammatory process extend- 
ing from the throat. 

Even where children have had several ade- 
noid and tonsil operations, there may be dis- 
eased tissue remaining that is walled in by 
cicatrices, thus preventing drainage. The 
child's health may be worse as a result of this 

29 



NUTRITION AND GROWTH IN CHILDREN 

condition than it was before the operation. 
Such infected tissue must be removed before the 
child is "free to gain." 

In Figure 8 is shown a composite graph of 15 
cases which required more than one operation 































Ga 


\n I 


>efx: 


re( 


Dpe 


rati 


on 


C 


ain 


afi 


■er 


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irai 


ion 




3 


oz. 


Der 


we< 


>k 


C 




\ik 


oz 


pe 


" week 
















.2 




























S? 




























CD 
Q 




























O 










































































Av< 


rac 


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alor 


es 






A 


ver 


aqe 


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ori< 


;s 




ier 


da' 


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zfo 


~e 






P 


er 


Jay 


af 


-er 






Opi 


raf 


on 


241; 


3 






o 




afro 


i 21514 





FIGURE 8. EFFECT OF ADENOID AND TONSIL OPERATIONS 

This chart shows the average gain of a group of 15 children after 
adenoid and tonsil operations, as compared with their gain before 
the operations — in the one case, 17% ounces a week, in the other, 3 
ounces, with practically the same amount of food. Their failure to 
gain while under' observation in the nutrition class was 
the determining factor in diagnosis. 

before the children could be made to gain satis- 
factorily. Their delay in growth was rightly 
interpreted as additional evidence of the pres- 
ence of diseased tissue in the throat causing 

30 



PHYSICAL-GROWTH EXAMINATION 

toxins to enter the body. It should be remem- 
bered that the effect of focal infection is more 
marked on the general system than on local tis- 
sues, so that poor physical condition may be 
stronger evidence of toxic effect than the ap- 
pearance of the throat itself. 

Sinus infection is more common than is gen- 
erally supposed. The sinuses in children are 
small, but infection may occur secondary both 
to naso-pharyngeal obstruction and to decayed 
teeth. 

Teeth Defects. — It is generally assumed that 
carious teeth cause malnutrition. A careful 
study made of several hundred children, how- 
ever, fails to establish this relationship. In 
fact there seems to be no evidence available 
that small cavities in the teeth directly affect 
nutrition unless there are also abscesses or 
other inflammatory conditions present. 

In the group studied * it was found that those 
who had carious teeth showed 7 to 22 per 
cent greater incidence of postural defects and 
4 to 16 per cent more obstructions to breath- 
ing than those who were free from teeth de- 
fects, but no such apparent relation to under- 



1 "Physical Defects in Children." Report of 602 
(Pamphlet No. 8 in List of Publications, p. 332.) 

31 



NUTRITION AND GROWTH IN CHILDREN 

weight was indicated. Even when the com- 
parison was made between the children having 
many and those having few defects of each kind, 
the proportion of underweight increased with 
the number of naso-pharyngeal defects but not 
with defects of the teeth. 

In another study, 2 88 children were divided 
into four nearly equal groups — the first having 
no carious teeth; the second, one each; the 
third, two and three; and the fourth, four to 
twelve. The percentages of malnutrition ran 
10, 9, 10, and 10, respectively, showing no sign 
of correlation. 

There are -excellent reasons for insisting 
upon the care of the teeth, but the studies that 
have been made do not justify the assumption 
that small cavities are a direct cause of malnu- 
trition. 

Medical Defects. — In extreme cases of mal- 
nutrition hereditary syphilis should always be 
suspected as a cause. Therefore the Wasser- 
mann test should be made as a routine matter, 
especially in institutional cases. X-ray exam- 
ination of the long bones is an aid in this diag- 
nosis. 



2 "A Nutrition Clinic in a Public School." (Pamphlet 
No. 1 in List of Publications, p. 332.) 

32 



PHYSICAL-GROWTH EXAMINATION 

Vaginitis of gonorrheal origin will also be 
found among cases admitted to institutions and 
out-patient departments. 

Pyelitis is not uncommon, especially in girls. 
The detection of this condition often requires 
more than one urine examination because of its 
remissions and exacerbations. 

An X-ray examination of the chest may dis- 
cover obscure tubercular lesions, and the von 
Pirquet test should be employed to rule out 
tuberculosis. 

Temperature charts are useful in determining 
obscure infections. Malnourished children fre- 
quently run a slight evening temperature, and 
in these cases observation in bed with a 4-hourly 
chart may be helpful. A sub-normal tempera- 
ture is a sign of low vitality, and may indicate 
the need for rest in bed. 

Intestinal parasites and their eggs should be 
looked for by an examination of the feces under 
the microscope. Eosinophilia may be another 
indication of worms. 

An X-ray examination of the alimentary tract 
will assist in the diagnosis of cardiospasm, 
pyloric stenosis, intestinal adhesions, or chronic 
appendicitis. 

Examination of the blood of malnourished 
children does not usually show anemia, al- 

33 



NUTRITION AND GROWTH IN CHILDREN 

though this condition may obtain as a result of 
the tea, coffee, or candy habit. 

Where there is an eczema or skin eruption, 
accompanied by bronchitis or asthma, a condi- 
tion of anaphylaxis is to be suspected, and the 
cutaneous proteid tests should be made. This 
is a not infrequent cause of malnutrition, and 
these tests are the best helps we have in arrang- 
ing a diet on which the child will gain. Im- 
paired ability to digest and assimilate food 
under this condition calls for longer rest pe- 
riods and special guarding against over- 
fatigue. 

Defects at Various Ages. — In a recent study 
of 602 children, ranging ; in age from 2 to 15 
years, we found an average of six defects per 
child. No evidence was shown of any particular 
period in which there is a greater tendency to 
defect, as there was remarkable uniformity in 
the number of defects at all the ages included. 

The significance of various defects may vary, 
however, with the age of the child. Because of 
the small size of the naso-pharynx, for example, 
an excess of adenoid tissue may be a serious 
danger during infancy and the pre-school age, 
while tonsils do not as a rule become infected 
before the age of five or six. Failure to gain in 
weight is often one of the earliest and most re- 

34 




Figure 0. deformity and malnutrition 



The true condition of those two school girls was brought out hv the 

physical-growth examination in a nutrition class conducted by thf 

Elizabeth McOormick Memorial Fund in Chicago. The usual medical 

inspection in schools docs not discover such basic 

defects of growth. 



PHYSICAL-GROWTH EXAMINATION 

liable signs of absorption from infected tissue, 
and the early removal of diseased adenoids and 
tonsils is important in preventing pyelitis and 
endocarditis as well as other serious complica- 
tions of the acute infectious diseases. 

The Examination Form. — All the defects 
most commonly found are printed on the exam- 
ination form used in our nutrition classes, and 
these are simply underlined as the examiner 
proceeds. The completeness of the form enables 
the parent or nutrition worker to check up the 
record and see that no detail is omitted. The 
advantages of this method of examination both 
in private practice and hospital work, may be 
summarized as follows : 

1. Records become valuable because they are 
standardized, and there are no omissions. 

2. Uniform and approved nomenclature is used. 

3. Dictation can be taken by any one who can 
read and write as well as by a stenographer, 
and at the conclusion of the examination the 
complete record is ready for inspection without 
having to be transcribed. 

4. This method makes it easier to equalize at- 
tendance at a clinic. New patients appreciate 
the completeness of the physical-growth ex- 
amination, and are willing to come again by 
appointment in case the day happens to be 
unusually busy. 

35 



NUTRITION AND GROWTH IN CHILDREN 

5. It aids the work of the less experienced physi- 
cian by listing completely the points to be ob- 
served. In general it may be said that mis- 
takes are made not from lack of knowledge on 
the part of the doctor, but because he has 
failed to look. 

6. It insures greater thoroughness. From 100 to 
200 per cent more abnormalities are found by 
this method than by the usual examination, 
even when made by specialists in the best 
clinics. 

7. It saves unnecessary repetition of examina- 
tions. Under the usual hospital procedure if 
a child returns to the clinic, he frequently has 
to be undressed and reexamined because previ- 
ous records are incomplete. 

8. Such basic examinations are accepted when a 
patient is referred to another department, be- 
cause the name of the examiner is on the form, 
and he can be held accountable for what he 
has signed. 

9. It adds interest to the work of the examiner, 
and enables him to receive credit for good 
work. It also increases work in preventive 
medicine because defects are almost invariably 
found other than those which brought the pa- 
tient to be examined. 

10. It assists the administrative and medical social 
service departments of the hospital by defi- 
nitely recording all abnormalities that need 
correction. 

36 



PHYSICAL-GROWTH EXAMINATION 

The following case admitted to one of our 
nutrition clinics illustrates this point: 

A child-helping institution inquired for a 
diagnosis of the condition of Charles S. The 
nutrition worker found his record, and was able 
to answer immediately : 

"Charles S. was examined here December 27. His 
general condition was found to be poor. He was 12 
per cent underweight for his height, had round should- 
ers, pediculosis, and two carious teeth. He had naso- 
pharyngeal obstruction, and was apparently retarded 
mentally. Treatment has been prescribed for pedicu- 
losis and an appointment made to have him examined 
in the throat department. He is to report here in a 
week, bringing a list of food taken during 48 con- 
secutive hours in order that his food habits may be 
determined. The examiner suggested that he be 
tested mentally, and that inquiry be made as to his 
work in school. After he gains in weight he should 
have corrective exercises." 

The inquirer replied : 

"That is just what we wanted to know," 

and added: 

"We will have the dentist attend to his teeth, and 
see that the directions for pediculosis are carried out. 

37 



NUTRITION AND GROWTH IN CHILDREN 



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38 



PHYSICAL-GROWTH EXAMINATION 

We had suspected a condition of diseased tonsils and 
adenoids, and shall be interested to receive a further 
report on that matter. We are glad to cooperate with 
you in regard to his food habits, and will arrange 
immediately for a special mental examination." 

At the end of six months Charles S. had 
gained normal weight, and was in excellent 
physical condition. His adenoids and tonsils 
had been removed, and all the treatment recom- 
mended in the physical examination had been 
carried out. He was found to be mentally re- 
tarded, and special classwork was provided in 
school. This was a direct saving of the teach- 
er's energy, for she had been giving him extra 
time after school in an effort to "keep him up 
with his class.' ' 

Contrast this report, and the constructive 
work accomplished in this typical case, with the 
reply that had been given in regard to the 
same boy following an examination made two 
weeks before he was admitted to the nutrition 
clinic : 

"Yes, Charles S. was examined, but evidently the 
doctor found nothing serious the matter with him, as 
he simply gave general directions about his hygiene, 
and advised that if he was not all right he should 
report again in two months." 

39 



NUTRITION AND GROWTH IN CHILDREN 

The relative results of the two methods of 
examination is shown in the foregoing table of 
defects found in 50 children who were patients 
in one of our largest and best organized chil- 
dren's clinics, as compared with the record of 
the same children examined in the nutrition 
clinic according to the basic method here de- 
scribed. The table shows first, the defects ap- 
pearing in the hospital diagnosis summary; 
second, additional defects mentioned in the gen- 
eral examination but not appearing in the sum- 
mary; third, the sum of these two columns, or 
all defects recorded as a result of the general 
examination; fourth, the defects found in the 
examination made at the nutrition clinic; fifth 
and sixth, comparisons in the form of percent- 
ages. 

It will be seen that the general examination 
recorded only 44 per cent, or less than half the 
defects appearing in the register of the nutri- 
tion clinic. When the number of defects ap- 
pearing in the diagnosis summary is compared 
with the nutrition record, the disparity is even 
greater, the summary recording only 21 per 
cent, or less than one-quarter of the actual de- 
fects. In the naso-pharyngeal group the sum- 
mary showed only 9 per cent of the defects 
found, and the nearest approach to the com- 

40 




Figure 10. six malnourished girls 



This is a group at the Massachusetts General Hospital, taken as thev 
sat in the nutrition class in the order of their irains for a week. Their 
serious expressions arc characteristic, quite unlike those of happv, well 
children of normal weight. Ohserve the round shoulders, thin arms, and 
protuberant abdomens. The physical-growth examination con- 
vinced their parents of the need of '"mmediate care. 



PHYSICAL-GROWTH EXAMINATION 

pletenoss of the nutrition examination was 47 
per cent in the case of teeth defects. 

This latter comparison with the diagnosis 
summary is a fair test of the two methods, be- 
cause the results of an examination are almost 
sure to be overlooked if they are not brought 
down to the summary, from which the recom- 
mendations are usually made. It may be urged 
that the general examination is especially con- 
cerned with vital organs, and consequently 
omits less serious defects, but an inspection of 
the details of the more complete examination 
shows no defects included that do not have 
direct bearing upon the child 's health. 

"Before and After" Pictures. — Pictures of 
the child taken " before and after' ' treatment 
(as illustrated on pages 45, 184 and 186) make a 
valuable supplement to the physical examina- 
tion. They should preferably be taken without 
clothing, but where this is not practicable any 
picture of the child will prove helpful. The "be- 
fore" pictures should be taken at the time of 
the examination and not deferred until the child 
begins to show improvement; and the "after" 
pictures should be taken in the same relative 
position in order to show the contrast after the 
child has reached his normal weight line, Care 

41 



NUTRITION AND GROWTH IN CHILDREN 

should be taken to make these photographs 
represent true conditions. 

In large clinics a single picture of several 
children in line can be taken. This picture will 
serve not only for group purposes by illustrat- 
ing the prevalence of certain conditions, such as 
fatigue posture, but it can be cut, and the single 
picture attached to the record will serve to 
identify the individual child. (See Figure 10.) 



CHAPTER V 

THE MENTAL EXAMINATION 

Malnutrition does not cause mental defi- 
ciency, but it does result, at times, in a mental 
retardation closely resembling the actual state 
of defect. Many children who are under par 
physically manifest symptoms that are inter- 
preted as indications of deficiency, when they 
are in reality signs of nervous strain and over- 
fatigue, or irritability and dullness resulting 
from toxemia that has a physical and remova- 
ble cause. 

Such children do not have the strength to 
show interest in their studies, and falter and 
fumble at their tasks in a way that is exasper- 
ating to those in charge of them. Considered 
lazy, they are told, "Your fingers are all 
thumbs," or " You never get anything 
straight/ ' or "If you have any brains, why not 
use them?" But such expressions merely add 
to the child's distress, and entirely fail to im- 
prove his condition, the real cause of which 
must be determined. 

The malnourished child is frequently back- 
43 



NUTRITION AND GROWTH IN CHILDREN 

ward, forgetful, unhappy, over-sensitive, and 
unreasonable both in his likes and his dislikes. 
He may show signs of irritability, fretfulness, 
peevishness, inattention, and lack of concentra- 
tion and yet be entirely normal in his mental 
development. 

Similarly, such physical abnormalities as 
hare-lip, arched palate, ill-shapen head, ear, or 
limb, are not conclusive proofs of mental defi- 
ciency, although they are more frequently found 
in mentally defective than in normal children. 
Individuals vary, but any wide variation, either 
mental or physical, should be investigated. 

It is the task of the nutrition clinic to de- 
termine by careful study and observation the 
significance of any of these symptoms that ap- 
pear in the children admitted for treatment. 
Mental development closely parallels physical 
development, and any failure on the part of a 
child to show the interests and activities usual 
in children of his age should challenge atten- 
tion. One of the best tests is the first impres- 
sion made on the examining physician. If, in 
addition to this, the history shows that the child 
did not walk or talk at two years, that he has 
been difficult to get along with, or defiant of 
fundamental social law, this combined evidence 
justifies a thorough mental examination. In 

44 




Figure 11. mental retardation or mental deficiency 



Tom was 11 per cent underweight, a mouth breather, with round 
shoulders, flat chest, spinal curvature, and flabby muscles. Ho was 
considered stupid, and kept after school in a vain attempt to hold him 
up to his grade. r n le right half of the picture shows him after his 
diseased adenoids and tonsils had been removed and he had followed 
directions as to diet and rest. The transformation in his con- 
dition can be seen to be mental as well as physical. 



MENTAL EXAMINATION 

most communities there are trained experts who 
can pass authoritatively upon a child's mental 
condition. In consulting such a specialist all 
available data from the nutrition class should be 
supplied him to aid in his investigation of the 
child's mental health. 

In questionable cases, however, the child 
should be given the benefit of the doubt, and an 
effort made to correct his malnutrition. It 
should be remembered that the unmanageable 
child is more often ill than bad or deficient. 
Any marked change in behavior suggests the 
onset of illness. Fretfulness from rickets, dull- 
ness and lack of memory from adenoids, irrita- 
ble peevishness from digestive disorders, and 
the abnormal mental reactions of overfatigue 
all yield to treatment when their cause is once 
recognized, and a mental transformation fre- 
quently takes place along with the physical im- 
provement. 

Even where the child is found mentally de- 
fective, he will be happier and his mental condi- 
tion will improve if his nutrition is brought up 
to normal. The condition should not be made 
an excuse for neglect or lack of control, which 
will merely aggravate his malady. 

Home conditions and early training in self- 
control are important factors in leading the 

45 



NUTRITION AND GROWTH IN CHILDREN 

child to normal behavior. I have seen this il- 
lustrated in the case of a boy who was so utterly- 
defiant of parental authority that he would 
actually fight his mother with feet and fists. It 
was thought certain the child was mentally de- 
ficient, but before accepting this explanation 
as final, it was decided to try what discipline 
and a change of environment would do. He was 
accordingly sent to a well organized boys' 
school, and at the end of the year the master 
reported, "He is a little gentleman." 

Life for many undisciplined children is an 
almost unbroken series of dissipations. What 
they want they must have at any sacrifice of 
health, or even of character. Such children be- 
come past masters in the art of getting their 
own way, and play the game to its limit. Many 
of these spoiled boys and girls, persisting in 
the attempt to have their own way, later in life 
overstep the moral law or the written statute, 
and bring upon themselves disgrace or the pen- 
alty exacted by the state. While their conduct 
indicates mental impairment, it may be only the 
logical result of lack of training. 

The mental progress of children from three 
years to 10 may be tested according to the 
following standards from the Binet- Simon 
series : 

46 



MENTAL EXAMINATION 

Three years: 

Points to nose, eyes, and mouth. 

Repeats short sentence. 

Picks out objects in picture. 
Pour years: 

Knows sex. 

Recognizes a knife, key, etc. 

Repeats three numerals. 

Distinguishes between long and short line. 
Five years: 

Distinguishes between two objects of different 
weight. 

Copies a square. 

Repeats sentence of eight or ten words. 

Counts four. 
Six years: 

Knows morning and afternoon 

Defines simple objects, giving the use as a defi- 
nition, for instance, a fork is to eat with. 

Carries out simple commands involving two 
or three things. 

Knows right and left. 
Seven years: 

Counts thirteen or more. 

Describes pictures. 

Copies other figures than squares. 

Knows colors. 
Eight years: 

Counts backward from twenty to one. 

Gives the essential difference between such ob- 
jects as glass and wood, fly and butterfly. 

Knows the days of week. 

Repeats five numerals. 
47 



NUTRITION AND GROWTH IN CHILDREN 

Nine years: 

Knows the date. 

Names months of the year. 

Makes simple change in handling money. 

Gives definition of objects other than by ex- 
pressing their use. 
Ten years: 

Knows money values. 

Repeats six numerals. 

Gives intelligent answers to simple questions 
involving thought; for example, "What 
would you do if a playmate struck you 
accidentally?" 

In suggesting these simple tests, that can be 
made by the mother in the home without the use 
of apparatus, Stearns says: 1 "Failure to re- 
spond to these tests . . . must be explained. 
Taken in conjunction with slow development in 
other things, they point toward permanent limi- 
tation of the possibility of intellectual develop- 
ment. Alone, they show that something is 
wrong, mental, physical, or educational." 

As children grow older, progress in school is 
significant evidence of mental development. A 
delay of a single year in passing to the next 
grade deserves consideration, and two or more 
years' retardation is serious. If there are no 

1 A. Warren Stearns, ''Practical Mental Examinations for 
Growing Children," No. 14 in List of Publications, p. 332. 

48 



MENTAL EXAMINATION 

physical conditions interfering with the child's 
progress, such retardation points to the desira- 
bility of special training adapted to the needs 
of the individual child. 

Borderline cases often escape observation be- 
cause some mental defectives manifest qualities 
of affection and amiability which cause their 
deficiencies to be overlooked. A child may be 
sub-normal in only one or two respects, and if 
these happen not to affect the standards of effi- 
ciency that are expected of him, they are liable 
to be neglected. If, however, they are moral 
defects or such as affect his ability to gain a 
livelihood, they will more easily be discovered. 

Unrecognized mental deficiency in malnour- 
ished children will sometimes explain the fail- 
ure to get results in cases which appear to be 
"free to gain." If a child is mentally deficient, 
there is always the possibility that one of the 
parents is likewise defective, and in this case 
untrustworthy and misleading reports will be 
given as to the carrying out of directions. A 
family of this sort, with several members 
slightly defective, may take up the time of 
social workers from various institutions with 
little or no result. The mother will passively 
accept advice, but do nothing, rendering num- 
berless visits to the home necessary. 

49 



NUTRITION AND GROWTH IN CHILDREN 

A study of the economic background and 
social relations of each child is important in de- 
termining accurately his mental as well as his 
physical condition. Such an investigation we 
call the social examination. 



. CHAPTER VI 

THE SOCIAL EXAMINATION 

After the j^hysical defects have been discov- 
ered through the physical-growth examination, 
aud the child's mental condition has been in- 
vestigated, the social examination is brought to 
bear on those factors that are concerned with 
the four remaining causes of malnutrition, 
namely : 

Lack of home control 

Overfatigue 

Improper diet and faulty food habits 

Faulty health habits 

The history record already described is the 
first source of social information, and often 
gives useful hints about the organization of the 
home and the kind of control that prevails there. 
This must be expanded by a careful investiga- 
tion of the child's life during the entire 24 
hours, and a diagnosis cannot be complete that 
considers only a part of that time. As many 
of the causes of malnutrition exist merely be- 
cause they are unrecognized, it is futile to at- 
tempt treatment without securing complete 

51 



NUTRITION AND GROWTH IN CHILDREN 

data as to the food and health habits of the 
child and all the conditions that may be causing 
overfatigue. 

The 48-Hour Record.— A record of the child's 
interests, activities, and occupations for two 
consecutive days, with a detailed list of all food 
taken during the same period, is the best ap- 
proach to a thorough understanding of the so- 
cial causes of malnutrition. A single day may 
be exceptional, but a schedule covering two con- 
secutive days will give a fair average of the 
usual routine. Friday and Saturday are good 
days to select because they will show the out- 
side activities as well as the school schedule. 

In order to gain a true knowledge of the 
child's habits this first record should be taken 
before any suggestions are made for their im- 
provement. It is usually a surprise even to well 
informed and observant parents to face this 
record in black and white, and it becomes ob- 
vious at once that changes are needed. 

The following schedules are typical of condi- 
tions appearing constantly in our nutrition 
classes : 

A Private School Boy Who Bolted his Breakfast 

Daniel C, 6 to 7 : 30 reads in bed ; 7 : 30 rises ; break- 
fast 7 : 45 ; bus to school at 8 ; in school 8 : 30 to 
52 




Figure 12. heredity is not usually the cause of 
malnutrition 



Mary and Alice are twins. At birth Mary weighed 4% pounds, and 
Alice. 5% pounds. Now. at the age of nine years. Mary weighs 14 
pounds more than her sister because Alice omitted milk and cereal 
from her diet. Mary has also outstripped Alice in height. 



SOCIAL EXAMINATION 

12; half hour recess for lunch; 12:30 to 2 in 
school ; 2 to 4 supervised play ; home at 4 : 30 with 
lunch on arrival; 5 to 6 reading or games; 6 to 
6 : 30 supper ; 6 : 30 to 8 home study ; retires at 
8:30. 

The hour and a half of reading in bed and the 
hurried breakfast made a bad start for the day, 
which was not offset by the advantages of an 
open-air school. The boy failed to gain until 
both these habits were corrected. 

Too Much Indoor Occupation 

Dorotliy S., rises at 7 ; breakfast 7 : 30 ; school at 8 : 30 ; 
recess 10:30; home for dinner at 12; school at 
1 ; out of school at 3 : 30 ; Hebrew lessons 4 to 6 
every day except Friday and Saturday; supper 
at G ; assists with housework, studies lessons, goes 
to bed at 9. 

This girl was on the waiting list at a neighbor- 
ing settlement to take piano lessons as soon as 
there was a vacancy. With such continuous in- 
door occupation it was not surprising that Doro- 
thy was sent to the nutrition class from a tubercu- 
losis clinic. 

Irregular Meals and Late Hours 

James G., 5 to 7 rises, chores, breakfast; 7 to 8:30 
trip to next town and half mile walk to rural 
high school ; 8 : 30 to 12 in school with 15-minute 
recess at 10: 15; 12 to 12: 30 cold lunch eaten in 
basement with other boys ; 12 : 30 to 2 in school ; 
53 



NUTRITION AND GROWTH IN CHILDREN 

2 to 4 return trip home with cold lunch on ar- 
rival ; 4 : 15 to 7 chores and supper ; 7 to 9 : 30 or 
10 reading, games, study, or moving pictures; 
9 : 30 or 10 to 5 sleep. 

A Fifteen- year-old Girl with a Sixteen-hour 
Schedule 

Isabel B., 5 : 30 or 6 to 7 : 15 rises, breakfast, gets 
ready for school ; 7 : 15 to 8 : 30 walks 15 minutes 
to car line, 30-minute ride on car, walks five 
blocks to school ; 8 : 30 to 12 : 15 in school ; 12 : 15 
to 12 : 45 recess and lunch ; 12 : 45 to 2 : 15 in 
school ; 2 : 15 to 3 : 30 return trip home with cold 
lunch ; 4 to 6 delivers milk to three neighbors, all 
on separate trips, making a walk of four miles; 
6 : 30 to 7 : 30 supper, washes and wipes dishes 
for eight persons ; 7 : 30 to 9 : 30 studies lessons ; 
9 : 30 to 5 : 30 or 6 sleep. 

The advantage of making these records is 
evident. No one concerned in the care of these 
children had any idea how much they were at- 
tempting to crowd into the child's day. A 
study of the daily program of almost any boy 
or girl reveals similarly unsuspected demands 
upon the child's energy. 

Overfatigue. — After analyzing the 48-hour 
record, further questions may be necessary to 
bring out the facts relating to overfatigue, such 
as: What part of the child's day is given to 

54 



SOCIAL EXAMINATION 

play, to work, and to school? How long is he 
actually in bed? How much of that time is he 
asleep? Has he learned to rest when not sleep- 
ing? What time does he go to bed? Does he 
rise in time to get to school promptly without 
hurry or worry? 

Home Conditions. — What are the require- 
ments made upon the child as a member of the 
family or household? Does he receive too much 
attention from older people? Does he receive 
enough? Does he like to play alone? Who are 
his chosen associates? What are his favorite 
forms of recreation? How is he punished? Is 
he obedient? What regular engagements has 
he in the way of scout duties, clubs, music or 
dancing lessons, gymnastic training, lessons in 
foreign languages or religion? 

Food Habits. — What is the average number 
of minutes spent at each of his meals? What 
are the interests that hurry him away from 
the table? Does he wash down his food with 
liquids? Does he drink tea, coffee, ice water? 
How much money does he have to spend for 
candy? Has he any marked likes or dislikes 
in the way of food? 

Health Habits. — How much of the child's 
day is spent in the open air? What are his 
sleeping conditions with reference to open win- 

55 



NUTRITION AND GROWTH IN CHILDREN 

dows, drafts, light, etc.? Does he sleep 
alone? Is he disturbed by other members of 
the family who retire later or rise earlier? 
Does he have a movement of the bowels at a 
regular time every day? Does he get his feet 
wet? How often does he bathe? 

The New Program. — A careful study of the 
replies to these questions will throw light on 
many possible causes of the child's malnutri- 
tion, and suggest treatment for their removal. 
In making up the daily program as few changes 
as possible should be made, and these with full 
consideration for the tastes and prejudices of 
the child in order that progress may be made 
along the lines of least resistance. The really 
wrong conditions should be determined, and all 
the force that can be brought to bear focused 
upon their correction; but too much interfer- 
ence in unimportant details will only defeat the 
main purpose, which is to make sure that the 
essentials of health are obtained. 

The new program should be checked up by a 
48-hour record each week. Where the children 
meet in nutrition classes, individual conferences 
following the class meeting will afford op- 
portunity for securing further information, and 
these may be supplemented by home visits 
where necessary. 

56 



SOCIAL EXAMINATION 



Foster Homes. — The 48-hour records have 
proved especially useful in the supervision of 
children placed in foster homes. In a class 



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Figure 13. an unhappy home 

Cynthia slowly gained in weight until the eighth week, when she 
hecatne unhappy in her foster home. This caused a loss of appetite 
with a consequent loss in weight. At the end of the twelfth week 
she was transferred to another home where she was happy. Her 
appetite at once improved, she gained rapidly, and in 
19 weeks went well "over the top." 

composed entirely of older children from such 
homes one of the girls continued to remain at 
the foot of the class, although there was no 
evident reason for her marked loss of weight. 
She was taking sufficient food to gain, 2,400 

57 



NUTRITION AND GROWTH IN CHILDREN 

calories, and the foster mother could appar- 
ently offer no explanation. When the child was 
questioned by herself, however, as to just what 
she did each hour of the day, she suddenly 
broke down and disclosed a schedule that might 
well have been taken from a tale of Dickens. 
This underweight, malnourished girl of twelve 
had been compelled to do the washing and iron- 
ing for a family of five, together with much 
other heavy work, and had been threatened with 
punishment if she should tell what she was 
doing. The state worker, after verifying the 
girl's account, transferred her to a better home, 
where an immediate gain in weight showed the 
quick response to proper treatment. 

This is, of course, an extreme case. Yet in- 
stances are not rare of ambitious and conscien- 
tious children in what are considered the best 
homes overworking themselves without pres- 
sure from either parents, or teachers — playing 
too hard, studying too hard, or working too 
hard. 

Summary of a Social Investigation. — In a 
large group of children who came under our 
observation after having been previously under 
the care of visiting nurses and social workers 
for a considerable period of time, we found 72 
per cent still using tea, coffee, or both; 64 per 

58 



SOCIAL EXAMINATION 

cent keeping late hours ; 28 per cent taking in- 
sufficient food ; 36 per cent eating too fast ; and 
54 per cent suffering from overfatigue due to 
extra work in clubs, classes, church, or indus- 
try. Several children in the group had scarcely 
a free half-hour in the whole week. 



PART II 

MALNUTRITION 
AND THE HOME 



CHAPTER VII 

THE ESSENTIALS OF HEALTH 

The growing child requires open air, suffi- 
cient food for growth, adequate exercise, and 
proper rest. Yet with all these requirements 
provided, many children nevertheless fail to 
develop properly and become seriously mal- 
nourished. Open air will not help the child 
unless he can breathe it freely into the lungs. 
Sufficient food may be available, and it usually 
is, but if food habits are wrong he will still be 
undernourished ; it is not so much what a child 
eats, but what he assimilates, that promotes his 
growth. He may have opportunity for exer- 
cise and rest, but unless properly employed, 
these in turn fail to insure normal growth and 
health. 

To overcome all obstacles in the way of the 
child's progress, as indicated by the foregoing 
discussion of the causes of malnutrition, a 
comprehensive program must be adopted that 
includes all the essentials of health. Reduced to 
their simplest terms, these may be re-stated as 
follows : 

63 



NUTRITION AND GROWTH IN CHILDREN 



1. The removal of physical defects 

2. Sufficient home control to insure good food and 
health habits 

3. The prevention of overfatigue 

4. Proper food at regular and sufficiently frequent 
intervals 

5. Fresh air by day and by night 



\ 


Home 


/ 


The 
-School 


The child's health 


Medical 
Care 


/ 


Child's own interest 


\ 



Figure 14. 



THE PARALLELOGRAM OF FORCES THAT SAFEGUARD 
THE CHILD'S HEALTH 



An analysis of this list makes it apparent 
that the necessary conditions can be readily es- 
tablished provided all forces that control the 
child's health are brought into cooperation. 
These controlling factors fall into four groups, 
constituting a parallelogram of forces that 
safeguard the health of the child. 

64 



ESSENTIALS OF HEALTH 

The first factor is the Rome; the second in- 
cludes those relations that are Medical in na- 
ture; the third group consists of the School and 
other social organizations; while, connecting 
and uniting them all, is the fourth force, the 
Child's Own Interest. Disregard of any one of 
these four forces may defeat what the others 
might accomplish, while a program that takes 
full account of them all insures rapid improve- 
ment in health and growth. 

A well organized nutrition class is the best 
agency for coordinating these forces in a pro- 
gram that provides a common appeal. Start- 
ing with a thorough physical examination, it 
undertakes to secure the cooperation of the 
home in carrying out the recommendations of 
the physician. Where school pressure is inter- 
fering with the child's progress, it assists the 
parent in securing a modification of the school 
program or such an adjustment of its schedule 
as will remove the occasion of overfatigue. By 
showing the needs of the malnourished chil- 
dren, and recommending their separation from 
the regular class until they are brought up to 
normal condition, it aids the school in maintain- 
ing its standards for the children who are well. 
The nutrition class also arouses the child's own 
interest so that he is willing to " train for 

65 



NUTRITION AND GROWTH IN CHILDREN 

health" and enter heartily into the plans made 
for his improvement. 

The Home. — It is discouraging for a mother 
who has reorganized her home life, planned for 
lunches and rest periods, and in every way made 
a business of caring for her child, to find that 
something outside the walls of her home is 
blocking his progress. Thousands of children, 
it is true, are being made well by the earnest 
and intelligent efforts of mother and child work- 
ing together with little outside help ; but unfor- 
tunately it is also true that many of the 
best home programs fail because, however 
strong the chain that the mother has forged, 
there are essential links beyond her im- 
mediate control that break with any sudden 
strain. 

The School. — In one instance, the child fails 
to gain because of long school hours or too short 
an intermission at noon. In another, the trou- 
ble is caused by the demands of clubs or 
other associations that it seems desirable the 
child should maintain. Even progress as a 
Boy or Girl Scout, or confirmation in church, re- 
quires extra study in a program already full to 
overflowing. The mothers and their children 
may be genuinely interested in health, but there 
is a conflict between the health essentials and 

66 



ESSENTIALS OF HEALTH 

these other interests that calls for adjustment 
and compromise. 

Every mother is forced to recognize these 
claims. Some look upon them as occasions for 
irritation, to be resisted as far as possible, 
while others are unwisely ready to give over the 
power of decision to the school or social worker 
concerned, or even to the child himself. The 
central responsibility, however, must remain 
with the parents, and when they call in the aid 
of any special worker or organization, they must 
see that the new activity fits in with the rest 
of the child's program; otherwise, instead of 
being better off from the new association, he 
may be merely the victim of added and conflict- 
ing pressure. 

Medical Care. — Many child-helping agencies 
whose efforts are well directed along one or 
more lines fail to secure substantial results be- 
cause they do not recognize the inter-relation 
of these forces in the child's life. This is, per- 
haps, most true in the case of medical care, 
which is an essential feature of the nutrition 
class program. More children are kept from 
normal development by not being "free to 
gain" than by any other single cause. Ob- 
structions to breathing and other physical de- 
fects are handicaps that offset the good that 

67 



NUTRITION AND GROWTH IN CHILDREN 

might otherwise result from careful instruc- 
tion in food and hygiene. A complete physical 
examination is the only sure method of deter- 
mining the medical causes of malnutrition, and 
no program that disregards this factor can 
hring about more than transitory improvement. 
The Child's Own Interest. — It is not neces- 
sary to remind parents or teachers that chil- 
dren willingly exert themselves for something 
in which they are interested, while it is impos- 
sible to bring their forces into action when they 
feel no concern in the object to be attained. As 
the malnourished child is frequently a "diffi- 
cult" child, and the carrying out of the health 
program demands both perseverance and self- 
sacrifice on his part, it will be seen how im- 
portant it is to arouse his own interest in his 
health and to secure his cooperation. In the 
nutrition class the weight charts visualize the 
progress made and stimulate the children to a 
healthy spirit of competition ; while the failure 
of those who do not follow directions, as well as 
the success of those who do, serves as a con- 
vincing demonstration to the whole group, and 
secures their cooperation and hearty support. 



CHAPTER VIII 

HOME CONTROL 

Malnutrition can often be traced to faulty 
home conditions, and in all cases the home is an 
essential factor in successful treatment. The 
physician can outline the important points of a 
health program, but its success will be in pro- 
portion to the degree of cooperation with which 
it is carried out by parent and child. It is well 
to consider what is the prevailing atmosphere 
of the home. Is it positive or negative, a place 
of hope and stimulation or one of repression 
and fear? Does its tone indicate hurry, injus- 
tice, worry, deception, or the opposite of these 
undesirable qualities? Do the children hear 
constantly, " Don't do this," and " Don't do 
that," or are they encouraged to try things out 
for themselves with a minimum of caution, but 
with help given freely when necessary? 

Home conditions affect all children, but they 
are of special significance in the lives of the 
malnourished. Good government in the home, 
as in the state, makes for happiness and health, 
and the principle of self-government will bring 

69 



NUTRITION AND GROWTH IN CHILDREN 

about surprising results in the matter of health 
once the child's own interest is aroused, and his 
attention directed to the subject intelligently. 

Training for Health. — There is powerful 
suggestion for good in such slogans as the Boy- 
Scout phrase, "Be prepared." Children are 
natural hero-worshipers, and the desire to be a 
good athlete, or to excel in games or other ac- 
complishments admired in others, will make 
many a boy and girl willingly accept self-dis- 
cipline that could not easily be imposed on them 
by others. Appeal should be made to the child's 
ideals through the reading of tales of hardi- 
hood and vigor. Nothing counts for more than 
the painting of mental pictures that reveal the 
possibilities of strength, force, and health in 
such vivid colors that the child will be inspired 
to make them realities in his own case. The 
child must be made to take a personal interest 
in his health. He should not follow the health 
program merely as a matter of routine and obe- 
dience, but should be so convinced of its value 
that no external discipline is needed to make 
him carry it out. 

This has been exemplified in numerous cases 
in our nutrition classes. One child will remind 
a forgetful mother of the time for lunches and 
rest periods; another will ask for more air in 

70 




Figure 15. a difference of five years in age and of 
four pounds in weight 

Paul is eight years old and weighs IVS pounds: his brother Ralph is 
three, and weighs liO pounds. Paul is stunted both in height and in 
weight becruse of improper food habits. The nutrition worker found 
that he was taking less food than that required by an infant of one 
year. He did not like milk, bread, butter, fish, or meat : he washed 
his food down with liquids ; and he was allowed to sit at the table and 
play with his food while the others were eating. His mother says he 
is "•irritable and cranky." Ralph, on the other hand, 
is strong, good-natured, and happy. 



HOME CONTROL 

the sleeping room; others give up tea and cof- 
fee, and teach themselves to like foods to 
which they previously had an antipathy. Chil- 
dren even persevere in their efforts when the 
cooperation of the home is lacking, or when un- 
able to continue attendance at the classes. 
After the summer vacation many reports of 
good gains are brought in to the clinic. In one 
case, a girl of 13 who had been absent over a 
year gained 15 pounds and came to claim her 
certificate, which she had won by her own efforts 
while her mother was away from home. 

Winning the Child's Confidence. — There is 
nothing of greater importance to a child than 
to feel that he is understood. The wise mother 
knows when a child is over-taxed, and makes 
proper allowance for him. She realizes that his 
disposition changes under stress, and says, 
truly, "He is not himself.' ' She studies to 
recognize the occasions on which this is a valid 
excuse, and tries to find the cause and remove it. 

A frequent cause of malnutrition is found in 
the child's feeling that he has been unjustly 
treated, and the fact that he may be mistaken 
makes the result no less serious. If the weekly 
weighing is made something of a ceremony, and 
the child sees that both parents are really in- 
terested in his condition, he will respond with 

71 



NUTRITION "AND GROWTH IN CHILDREN 

an unusual degree of confidence. It is impor- 
tant to find out what the child really cares for 
and fears. Some trifling matter may be caus- 
ing a distress that interferes with normal 
growth. Counter-suggestion, it should be re- 
membered, is much more effective than repres- 
sion, and it has only recently been recognized 
how much fear, apprehension, and distress in 
later life are due to repression in childhood. 

The Correction of Bad Sex Habits. — Many 
mothers are much concerned about the effect 
upon the children's health of bad sex habits. 
This is naturally a matter about which it is not 
difficult to have misunderstanding. A feeling 
of delicacy and reticence often leads to sus- 
picions that read into some simple statement or 
act much more than belongs to it. It is easy to 
look at these matters from an excessively moral 
standpoint, and to fail to see the normal physi- 
cal and mental aspects that may need attention. 
Boys and girls are, on the whole, a level-headed 
lot, and they usually understand such matters 
in a healthy way. 

With a little child a tendency to masturbation 
should be met in the same manner that one 
would deal with biting finger nails or sucking 
thumbs. It may require some simple punish- 
ment to prevent the formation of this habit, but 

72 



HOME CONTROL 

the child should not be led to focus attention 
upon the subject. 

An older child suffers more from the effects 
of worry about what he fears may be wrong 
than from any other cause. This worry is often 
serious, and the air of mystery and secrecy 
with which adults treat the subject only makes 
a bad matter worse. It may be comforting to 
parents to know that in a most careful investi- 
gation that we have made recently we have 
not found a single instance in which bad sex 
habits had caused malnutrition. Among men- 
tally deficient children, 'the presence of these 
habits is an effect of their mental condition, and 
is rarely, if ever, the cause. 

Selfishness in Parents and Children. — Much 
of the self-indulgence that wastes a child's life 
grows out of the self-indulgence of older peo- 
ple. The mother who lets her child "have his 
own way" is often gratifying her own pleasure. 
By making a pet of him she seeks to make him 
dependent solely on her for his happiness and 
comfort. She encourages him to come to her 
with little ailments and symptoms, and sympa- 
thizes with his sensitiveness instead of teach- 
ing him to meet small hurts and disappoint- 
ments with self-control. The problem of the 

73 



NUTRITION AND GROWTH IN CHILDREN 

spoiled child is too often the problem of the 
spoiled mother. 

The thought that even little children can do 
something helpful for other members of the 
family will do away with many tendencies to- 
wards selfishness. The child should be encour- 
aged in the normal wish to help by having his 
activity directed into useful avenues. His de- 
sire to be useful begins to show itself when his 
actual accomplishment amounts to little, but his 
attempts should nevertheless be encouraged. 
The failure to help later when his work would 
be worth more may be due to the fact that the 
earlier impulse was not turned into a habit of 
helpfulness. 

Self-reliance and readiness to cooperate 
furnish the best basis for health as well as for 
happiness. The child should be taught to as- 
sume responsibility from his earliest years. 
Apart from the value of the service, there is the 
importance to him of having a constructive and 
responsible attitude towards life. How many 
parents, instead of giving the child the needed 
instruction, will say, "I'd rather do it myself 
than be bothered with him. ' ' On the other hand, 
it is possible to go too far in this direction, and 
to lay burdens upon a child heavier than his 
strength should bear. 

74 



HOME CONTROL 

Many cases of malnutrition are a direct re- 
sult of over-indulgence for which the "spoiled 
child' ' pays a heavy penalty. The malnour- 
ished child is apt to be the only child, or else 
the youngest or the oldest — the "pet" who has 
got the upper hand of the father and the mother. 
It is evident in many homes that the child is in 
control, and the parent his willing or unwilling 
slave. If he does not wish to do a thing, he has 
no idea that there is any reason why he should, 
or any power to compel him. Nothing can be 
accomplished in such a home until it is made 
clear that there is some one besides the child 
who is directing the course of his program. 

The tendency to undue self-assertiveness ap- 
pears naturally at a certain age, and would soon 
disappear if properly met and handled. Dis- 
plays of temper are usually practiced because 
they have proved a successful means of getting 
what the child wants. If encouraged in his de- 
fiance of authority, he may become saddled for 
life with a disagreeable and unfortunate habit. 

The Influence of Suggestion and Competi- 
tion. — Malnourished children are especially sus- 
ceptible to suggestion, and fears once impressed 
upon them are almost impossible to eradicate. 
Their condition should always be spoken of 
hopefully in their presence. They should be 

75 



NUTRITION AND GROWTH IN CHILDREN 

impressed with the fact that it is normal to be 
well, and should not be allowed to think of them- 
selves as invalids. 

Among the poor we find many children who 
are kept from normal growth by worry over the 
payment of rent, the care of younger children, 
the fear of the father's losing his job. Even 
in the homes of the well-to-do, young children 
come to know too much about the anxieties and 
difficulties that oppress their parents. They 
should not be allowed to enter into the discus- 
sion of family problems, or made to share anx- 
iety over conditions that they cannot help to 
control. 

Perhaps the most powerful influence in a 
child's life is the approval of his associates. 
He is quick to detect what is considered "good 
form" in the group to which he belongs, or 
wishes to belong. The spirit of competition 
makes a strong appeal, and a boy will spur 
himself on to achieve what others of his group 
have accomplished. This is one of the great 
advantages of association in nutrition classes. 
But even when the child is alone, he has his own 
normal weight standard with which to compete, 
and this is the goal that will help to enforce the 
rest periods, extra lunches, early hours, and 
other features of a good health program. 

76 



HOME CONTROL 

Punishment Should Be Constructive. — It 
should never be forgotten that punishment is 
always an individual problem. A little study 
of the child's nature will show how to be just 
and fair to him, and only on that basis can his 
respect and affection be retained. The right 
kind of punishment tends to do away with the 
necessity for its repetition, and the aim should 
be to make it easier for the child to do what is 
best for his health rather than to "have his 
own way" and do himself harm. 

Happiness has a positive health value, and 
wrong methods of punishment are a frequent 
cause of malnutrition. In the ideal home there 
is a healthy, normal attitude that seems to keep 
the child away from acts that call for punish- 
ment. When the need does come, it should be 
met in a constructive spirit, with no evidence of 
retribution or bad temper. 

One of the most serious cruelties practiced 
upon a child is the withholding of an expected 
punishment until the following day. Punish- 
ment should be prompt, although if there is any 
reason for doubt, justice should not be sacrificed 
to promptness. To punish justly it is neces- 
sary to know the reactions of the individual 
child. Unfortunately, much punishment is 
given as a matter of form, with little more than 

77 



NUTRITION AND GROWTH IN CHILDREN 

superficial results, and many mothers show a 
singular lack of imagination when confronted 
by a situation requiring discipline. 

Physical punishment is rarely necessary, and 
should be used experimentally, and only as a 
last resort. When it is really needed and is 
well used, it may prove very effective. 

Sending a child to bed without supper is in- 
excusable, and is particularly ill-advised in the 
case of the malnourished child. On the other 
hand, taking away privileges is a sound method 
of discipline. This may take the form of ad- 
vancing the usual bedtime for a short period, 
which will have the benefit of reducing the 
child's activities and increasing his time for 
rest. Especially good conduct may be recog- 
nized by shortening the time of the early-to-bed 
sentence, and further misdemeanor punished 
by extending its duration. 

Responsibility of the Parents. — In the com- 
plicated conditions of modern life parenthood 
is more than ever an art calling for great skill 
and judgment. Where bad control has existed 
for some time, it may be necessary to separate 
a mother and child for a short period. We have 
had many cases in which children failed to 
gain, or continued to lose, while under the care 
of the mother, and began at once to climb to 

78 



HOME CONTROL 

their normal weight line as soon as an aunt, or 
cousin, or grandmother took them in charge. 
Similar improvement is often effected when the 
child is placed in a well organized school. 

To control all the factors affecting the health 
of their children the interest of the parents 
must extend beyond the home to church, school, 
playground, club, and every other center of 
their activity and interest. In Chapter I we 
list lack of home control as one of the principal 
causes of malnutrition, but it is, in fact, di- 
rectly or indirectly responsible for all the 
others. If there are physical defects present, 
it is the parents' duty to see that they are re- 
moved; faulty food and health habits must be 
corrected in the home ; and overfatigue, whether 
from work, study, or play, can be avoided only 
by the watchful supervision of thoughtful 
parents. 



CHAPTER IX 

OVERFATIGUE 

Continued experience in the treatment of 
malnutrition leads me to the belief that there 
is no responsible cause for this condition more 
frequently overlooked than habitual over- 
fatigue. It is hard for grown people to realize 
how many and how wearing are the activities 
of the child, and even where it is recognized that 
the child is overtired, the condition is assumed 
to be a temporary discomfort, rather than a 
serious cause of permanent injury. 

Fatigue and Overfatigue. — It is necessary to 
distinguish between the fatigue that is a na- 
tural result of exertion, from which there is a 
quick recovery, and overfatigue, which carries 
the child each time farther from his normal con- 
dition, and makes his return to health more dif- 
ficult. In this case the child is either overstimu- 
lated so as not to know that he is tired, or else 
he has a disinclination for exertion of any kind, 
and a feeling of being dragged out and ex- 
hausted. 

The problem of overfatigue has been one of 
80 



OVERFATIGUE 

the most difficult problems of the physiologist. 
There is no single test or group of tests that will 
serve as an accurate measure of fatigue, and 
we must be guided therefore by practical obser- 
vation of the physical condition of the child and 
his reactions to his various tasks. The weight 
curve is the most valuable test available to 
show the effect of fatigue. If the child fails to 
gain after other known causes for his loss of 
weight have been removed, overfatigue must 
always be suspected as the cause of his poor 
condition. Usually, a modification of the men- 
tal or physical program, with increased rest 
periods, will bring about a prompt gain and 
demonstrate that overfatigue has been the ob- 
stacle to progress. 

No one experienced in the care of animals 
allows them to be over-exercised during the 
growing period. A valuable colt is never en- 
tered in long races until maturity, and it is 
recognized that a horse can be killed by over- 
driving or by being fed immediately after 
severe exercise. There is need for similar cau- 
tion in the care of the growing child. 

Causes of Overfatigue. — There are a thou- 
sand causes of overfatigue. The child will na- 
turally overdo, and the brighter and more active 
he is, the greater the danger. The spirit of 

81 



NUTRITION AND GROWTH IN CHILDREN 

competition and the desire to stand well with 
his associates leads him to undertake tasks far 
beyond his strength. This may be seen most 
frequently in play, where many a child is led 
through the influence of his comrades to enter 
into contests calling for both mental and physi- 
cal endurance, when he has no energy to spare 
for such strenuous exertion. 

Adults seldom appreciate how much energy 
and strength are required in simply growing. 
They do not take into account how often the 
child is over-taxed in trying to keep up with 
older people, not only in walking, for example, 
but in adapting himself to the various tools and 
equipment of a world that is designed for 
grown-ups. 

A written record of the child's activities for 
48 hours will surprise almost any parent in its 
revelation of unnoticed occasions of fatigue. 
This is especially true during the earlier years. 
From the age of two to six the child is apt to 
be made the pet of the family, each member in 
turn entertaining him, seldom leaving him 
alone, and often interrupting his proper rou- 
tine to gratify the wish to be with him. Spurred 
on by one stimulus after another, the child is 
tired out at the end of the day, but may have 
his bedtime delayed for the father's return, 

82 



OVERFATIGUE 

and his sleep disturbed again in the morning 
so that the father may see him before leaving 
home. 

The 48-hour record (as described in detail 
under the Social Examination, Chapter VI) 
should be analyzed, and every item challenged 
to see if it is a necessary tax on the child's 
strength. His program should then be cor- 
rected so as to provide for an improved expen- 
diture of time and energy. 

Rest and Sleep. — The amount of sleep needed 
varies with the individual, but every malnour- 
ished child should spend at least from 10 to 12 
hours in bed every night. Some get their best 
sleep early in the night, while others sleep 
better in the morning. The greater number of 
" nervous' ' children seem to be of the "morn- 
ing" type. The same individuality is evident 
in all forms of fatigue. Each child has his 
own way of becoming tired, which may be very 
unlike that of other members of the family. 
The same cause may show effect in various 
ways and in different parts of the body. 
"Nervous" children frequently show fatigue by 
restlessness, tossing in their sleep, and night- 
mare. 

In addition to the night's rest, regular rest 
periods in the middle of the morning and the 

83 



NUTRITION AND GROWTH IN CHILDREN 

middle of the afternoon are recommended for 
all children who fail to gain when following the 
nutrition program, and whose malnutrition is 
found to be the result of overfatigue. These 
rest periods have the effect of shortening the 
periods of activity, and therefore preventing 
further fatigue, while the rest and sleep restore 
the waste of past activity. The rest periods 
also increase the child's power of food assimi- 
lation. Fatigue interferes with absorption, and 
the child will benefit in both appetite and diges- 
tion if he has a short rest before eating. 

The proper position for the rest periods is 
shown in Figure 16. The clothing should be 
loosened, the windows open, and the child 
should face away from the light. He should 
not be allowed to take either books or toys 
to bed with him. Children should be taught 
to rest even when not sleeping, although the 
regularity of the rest periods when faithfully 
followed seldom fails to induce sleep. The 
rest period should be for at least half an hour, 
but 20 minutes of complete rest are worth more 
than an hour spent tossing about in discomfort. 
The ability to sleep for short periods at any 
time is a habit that makes for health. 

In extreme cases, absolute rest in bed for sev- 
eral days may be the means of causing the first 

84 




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OVERFATIGUE 

gain. In other instances, it will be better for 
the child to have breakfast in bed at his regular 
hour, and then continue to rest until 10 or 11 
o'clock. He should not be allowed to sleep 
through his usual breakfast time, and thus lose 
the value of regular meals. 

During the early years of childhood discre- 
tion should be used in story telling at bedtime. 
At the age of four or five the imagination is 
especially active, and exciting stories often af- 
fect the child painfully, causing fear of the dark, 
of unusual sounds, and of strangers. The child 
should go to bed happy and contented, under 
conditions that assure warmth and comfort, and 
with the distinct idea of going to sleep at once. 

As light is a powerful sensory stimulus, there 
should be no light in the sleeping room. It has 
been demonstrated that the depth of sleep is 
much greater during the dark nights of winter 
than during the lighter nights of summer. 
Children should not be permitted to sleep 
in underclothing that has been worn during the 
day. Their sleep should not be disturbed by 
the later retiring or earlier rising of other mem- 
bers of the family. 

Among older children it is necessary to limit 
the activities that tend to prolong their day. 
After a full school schedule, with home study 

85 



NUTRITION AND GROWTH IN CHILDREN 

and some share in household tasks or chores, 
it is natural for the child to wish to have some 
amusement in the evening. With each succeed- 
ing year these social demands increase their 
pressure, and are fraught with the greatest dan- 
ger for those children who are below normal 
weight. A short vacation filled with social dis- 
tractions may offset the gain made during a 
whole year. Nearly 40 per cent of all malnour- 
ished children keep late hours. 

The Strain of School Life. — It is difficult to 
gage or measure the utter fatigue of the mal- 
nourished child in his struggle to meet stand- 
ards that are frequently too high even for 
those who are well. This is especially the case 
in school life, where our very efficiency in em- 
ploying the spirit of competition is a source of 
peril to the undernourished. Children are 
urged on by such slogans as " Never give up" 
and " Always say, 'I'll try,' " while to this ap- 
peal to pride and honor their comrades add the 
spur of " Don't be a quitter." 

A school committee chairman of long expe- 
rience told me that in an investigation of the 
causes of truancy one of the children told him 
he stayed away from school because he "got 
tired of the teacher's voice." This child was 
suffering from overfatigue, and if this condi- 

86 



OVERFATIGUE 

tion had been better realized the matter of his 
school discipline might have been greatly sim- 
plified. Few adults feel equal to concentrated 
mental effort for more than an hour or two at a 
time, yet many schools expect three and four 
hours of continuous application from under- 
nourished children. 

That this long school program is not neces- 
sary for all children is proved by the fact that 
many of the children in our nutrition classes are 
able to keep up with their grade when excused 
at the middle of the morning session. The 
daughter of a physician was taken out of school 
entirely, but was able to make the same progress 
as her class upon an hour's tutoring a day. 
This subject of the school program is of so 
much importance that it will be separately dis- 
cussed in Chapter XXII. 

Outside Studies and Clubs. — During the late 
war many schools kept the children after hours 
for knitting, sewing, and other patriotic work. 
The fact that attendance was not compulsory 
did not remove the pressure of the suggestion 
that it would be selfish or unpatriotic to with- 
draw. 

Even religion may be the occasion for check- 
ing growth. Long church services, Sunday 
school, choir rehearsals, revivals, and other re- 

87 



NUTRITION AND GROWTH IN CHILDREN 

ligious observances impose a greater strain than 
the malnourished child is able to bear. Among 
the Hebrews, children are expected to spend 
from four to eight hours each week studying 
Biblical history and the Hebrew language, and 
these classes are often held in badly ventilated 
and poorly lighted rooms. 

Music lessons and dancing classes are other 
sources of strain and fatigue that should be 
omitted during the period of treatment. 

The child 's program is further complicated 
by the numerous clubs organized for his wel- 
fare or improvement. Each of these, however 
commendable in itself, takes its toll of strength 
and energy, especially from the child who is 
always stimulated to do his best and to keep up 
with his fellows in any undertaking. A little 
girl of ten in one of our nutrition classes was 
found to be connected with 11 of these organiza- 
tions, and the price paid in one week was lit- 
erally a pound of flesh ! 



CHAPTER X 

MEASURED FEEDING 

The feeding of infants has become so thor- 
oughly standardized that the amount of milk 
and other foods required is now prescribed with 
great exactness. In the case of older children 
this precision does not obtain, and the feeding 
of children above the age of two is still largely 
a matter of guesswork or caprice. This care- 
less feeding of the older child is responsible for 
many of the serious diseases of early life, and 
especially for many disturbances of the ner- 
vous system, which are difficult to remedy. It 
is one of the most common causes of malnu- 
trition. 

Some one has well asked, "Why do physi- 
cians exercise so much care in prescribing drugs 
that are administered only occasionally, and so 
little care in prescribing food which is taken 
daily?" 

To overcome this haphazard method of feed- 
ing something more than the general advice 
usually given is necessary. It is true that the 
child should have "good, nourishing food and 

89 



NUTRITION AND GROWTH IN CHILDREN 

plenty of it"; and that he should not take 
" anything indigestible.' ' But the fact remains 
that every growing child needs a certain total 
amount of food daily to supply him with the 
energy required for his normal activities and 
growth, and the only way to determine whether 
he is taking this amount is by a careful method 
of measured feeding. 

Food Values. — For the proper feeding of the 
child both parent and physician should have an 
adequate knowledge of food values, covering at 
least the principal items of food in common use. 
Three methods for determining food values are 
available. One in portions of 100 grams with a 
table of equivalent caloric values; a second, 
taking as a unit the ordinary serving; and a 
third, in portions of 100 calories, with an equiv- 
alent table of weight by ounces. As food is 
bought by the ounce or pound, the first method 
requires a mental readjustment, which makes 
it difficult of adoption by most persons con- 
cerned with the diet of children. All infant 
feeding in this country is by ounces, and change 
to another standard of measurements is im- 
practical except for laboratory work. The sec- 
ond method is unreliable because what is an or- 
dinary serving for one person is a very different 
quantity for another. 

90 



MEASURED FEEDING 

In our nutrition clinics we have therefore 
adopted the third method, which is that pro- 
posed by Irving Fisher in 1906, and is called the 
calory per cent method. Professor Fisher's 
tables indicate the amount of each kind of food 
necessary to furnish 100 calories of food value, 
and these amounts are used as standard por- 
tions. For example, one slice of bread has a 
value of 100 calories ; also, one pat of butter, the 
lean meat in an ordinary lamb chop, one slice 
of bacon, or five ounces of milk. A table cover- 
ing the principal items of food in 100 calory 
portions, with the proportion of proteid, fat, 
and carbohydrate, will be found at the end of 
this chapter. 

These units or multiples of units can readily 
be made the basis for the serving of food, and 
an accurate record can be kept without diffi- 
culty. Liquid measure is convertible into 
ounces on the basis of eight ounces to the glass 
and one-half ounce to the tablespoonful, and 
the rough measure by size, tablespoonful, etc., 
can be verified by finding on postal scales the 
actual weight of the portion served. Where the 
exact measure of proteid, fat, or carbohydrate 
is desired, as in cases of nephritis, jaundice, or 
diabetes, the total number of calories of proteid 
or carbohydrate may be divided by four, and 

91 



NUTRITION AND GROWTH IN CHILDREN 

the total amount of fat by nine, to give the 
equivalent value in grams. 

One of the great advantages of this method 
of measured feeding is that it gives a basis for 
visual comparison of food values, and a knowl- 
edge of the caloric value of the foods that it 
is necessary to consider in a given case can be 
acquired in a comparatively short time. 

A Food Exhibit. — A food exhibit arranged 
in 100 calory portions will help to fix relative 
values in the memory. 1 Figure 17 shows such 
an exhibit, from which it will be seen that such 
inexpensive foods as cereals are high in food 
value, and that it takes a quart of thin soup to 
equal in value a pat of butter, an egg, or five 
ounces of milk. 

A Diet Record. — The food habits of children 
are so constant that a record of the food taken 
during two consecutive days each week is a suffi- 
ciently accurate indication of the child's cus- 
tomary diet. If he eats less on one day, he will 
make it up the next, and vice versa. We there- 
fore require from each child a 48-hour record 
of all food taken, measured according to the 
directions given, and the average of these two 

1 Excellent food models can be obtained from The Plastic 
Art and Novelty Company, 1495 Third Avenue, New York 
City. 

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days represents the habitual daily intake of 
food. 

In the application of this method it is im- 
portant to secure the first record before making 
any suggestions as to change in diet, in order to 
learn the patient's previous habits. This pre- 
liminary record will show, not only the kind 
of food indulged in, but how much is habitually 
taken, and, more important still, the likes and 
dislikes of the child. It is always well to defer 
to taste as much as possible, retaining in the 
diet such wholesome foods as are agreeable to 
the child and making the necessary adjust- 
ment by substituting other foods for those that 
should not be taken. 

The preliminary list is often the first relia- 
ble knowledge obtained by parent or physician 
on which to base an attack on the fundamental 
cause of the child's malnutrition. Mistaken 
ideas as to food values are also revealed by this 
method, with its record in plain figures. A girl 
of 14 came under my care because she was un- 
dersized and delicate. For years she had taken 
daily a large serving of clear soup, the stock 
of which was made from the most expensive 
cuts of meat, which her father thought especially 
nutritious, not knowing that it requires nearly 
a quart to equal the value of a pat of butter. 

93 



NUTRITION AND GROWTH IN CHILDREN 

After taking this soup she ate very little else at 
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Figure 18. insufficient food — thin soup 

Lillian was in the habit of taking a large bowl of thin soup at the 
beginning of her dinner. This spoiled her appetite for the rest of 
the meal, and her diet list averaged only about 1,100 calories. 
When the soup was omitted, she ate more nourishing foods, and 
her chart shows an immediate and rapid gain in weight. 



value of her 24-hour ration by an appreciable 
amount. This effect was not apparent to either 
parent or physician until the total amount of 
food was measured. By omitting the soup 

94 






MEASURED FEEDING 

other foods of higher caloric value were nat- 
urally substituted, and the child at once began 
to gain. Two years later she returned for 
treatment because of overweight. 

It is surprising what gross errors are made 
in diet until one is faced with the exact list of 
what is eaten. One mother remarked of her 
son's list: "John calls this his diet list; I call 
it his confession/ ' 

How to Make Changes in the Diet. — Having 
obtained from the 48-hour record a knowledge 
of the kind and quantity of food taken, it is an 
easy matter to increase or decrease the 24-hour 
total by simple changes. For example, in the 
diet list of a nine-year-old child in one of our 
classes a very inadequate breakfast was re- 
corded, which, by simple changes, was doubled 
in value. 



BREAKFAST I 








Calories 


Cream of wheat 


4 tablespoonfuls 


100 


Sugar 


2 teaspoonfuls 


50 


Egg (soft boiled) 


One 


100 


Roll 


One 


100 


Butter 


Half-pat 


50 


Tea (milk and sugar) 


1 cup 


50 


Total calories 




450 



95 



NUTRITION AND GROWTH IN CHILDREN 



BREAKFAST II 




Cream of wheat 


4 tablespoonfuls 


Calori< 
100 


Cream (16%) 


3 ounces 


150 


Sugar 


2 teaspoonfuls 


50 


Egg (scrambled — 1 egg, 






1 ounce cream, V2 pat 






butter) 




200 


Toast 


1 slice 


100 


Butter 


1 pat 


100 


Cocoa 


6V2 ounces 


200 


Total calories 




900 



By taking cream with the cereal, and scram- 
bling the eggs with cream and butter, 250 calo- 
ries were added to Breakfast I. By substitut- 
ing cocoa for the tea, and taking a whole pat 
of butter with the toast 200 calories more were 
added, thus doubling the value of the meal. 
These changes were made without conflicting 
with the child's taste and without upsetting the 
home menu. 

Such changes do not force the child to take 
too much food at one time, and there is, there- 
fore, little danger of causing indigestion. The 
undernourished child is like a person conval- 
escing from a severe illness, requiring two or 
even three times as much food as is needed 

96 






MEASURED FEEDING 

when he is in normal condition. Children who 
are underweight seem to have a remarkable 
ability to digest food, while on the other hand, 
in the case of those who are overweight, symp- 
toms of indigestion disappear with a diminu- 
tion of the day's ration. 

An Aid to Diagnosis. — Undernourished chil- 
dren almost invariably take too little food, and 
underfed children all show signs of malnutri- 
tion. If a prompt advance in weight does not 
follow increased feeding, it is probable that 
some organic disturbance or other unfavorable 
condition is the obstacle to progress. Measured 
feeding is therefore a valuable aid in medical 
diagnosis. 

It is a futile but common expedient to give 
children tonics, transport them to different cli- 
mates, and subject them to all kinds of treat- 
ment, in order to cause a gain in weight, when 
a record of their diet often shows that they are 
taking not more than 1,000 calories per day. 
This amount represents the food requirements 
of a healthy infant, and could not provide for 
gain in an older child unless he were actually 
confined to bed. 

Increasing the 24-Hour Amount. — During the 
time the child is under treatment the amount of 

97 



NUTRITION AND GROWTH IN CHILDREN 

food can be increased most easily by adding 
mid-morning and mid-afternoon lunches to his 
usual three meals a day. He will assimilate 
more food in five light meals than in three 
heavier ones. These lunches should consist of 
easily digested food that will not destroy the 
appetite for the next meal. Sandwiches, bread 
and milk, or oatmeal crackers with fruit are 
suitable and satisfying. Sweets should be 
avoided unless in the form of prunes, figs, or 
dates. These extra feedings should have a 
value of 200 to 400 calories, and should be as 
regularly timed as the principal meals. 

The Amount of Food Needed. — The follow- 
ing table shows the approximate caloric re- 
quirements for a child of normal weight. The 
growing child's need is relatively greater than 
that of the normal adult, because of his in- 
creased activities and growth. For a malnour- 
ished child of six to 14 years of age, who is 
seven or more per cent under weight for height 
and continuing his usual activities, between 
2,000 and 3,000 calories per day are necessary 
for proper gain, but such children frequently 
take as much as 5,000 calories daily. The 
amount of food needed is measured by the 
growth to be accomplished and the energy to be 
spent in work and in play. 

98 



MEASURED FEEDING 
Table II. — Approximate Caloric Requirements in Health 



Age 


Calories per pound 


Total Calories in 
24 hours 


1 


4050 


350- 950 


2 


40-45 


900-1100 


3 


38-43 


1100-1300 


4 


35-40 


1300-1400 


5 


34-39 


1400-1500 


6 


32-38 


1500-1600 


7 


32-38 


1600-1700 


8 


32-38 


1700-1900 


9 


32-38 


1900-2100 


10 


33-38 


2100-2300 


11 


33-38 


2300-2500 


12 


33-38 


2700-2900 


13 


33-38 


2900-3200 


14 


32-38 


3200-3400 


15 


28-38 


3300-3900 


16 


26-36 


3200-4100 


17 


24-33 


3100-3900 


18 


23-30 


3000-3700 


Adult • 


18-24 


2600-3300 



* Male 150 pounds. Female 130 pounds. 

The large range in the number of calories is 
required on account of differences in activity, 
power of assimilation, and rate of growth. At 
any given age the greater the weight the smaller 
the number of calories needed. Therefore the 
smaller number of calories in the table should 
be the guide for heavier children and the maxi- 
mum the standard for children of lower weight. 2 

Every child requires sufficient calories to 
keep his weight at the point that is normal for 
him, and this is usually the weight at which 
he feels best. The 48-hour record should be 

2 See table of average weights for given heights in Ap- 
pendix I, p. 305. 

99 



SN 



NUTRITION AND GROWTH IN CHILDREN 

kept, and the patient weighed once a week, until 
his food requirements are known. The normal 
child can then be made to gain, lose, or remain 
stationary in weight as desired. 

Table III. Quantities of Food Necessary to Yield 100 

Calobies, with the Pbopobtion of Proteid, Fat 

and Carbohydrate * 



ts = teaspoonful 


tbsp = 


tablespoonful 


h = heaping 


aver = 


average 




sq =± square 


quar = 


quarter 




Fish 


and Meat 




Calories 






Oz. 


P. F. Ch. 


Cod, boiled 


N 02 


f 3.6 


90-10-0 


Haddock, broiled 


« o 1 


3.3 


90-10-0 


Bluefish, broiled 


|| 2 < 


2.4 


71-29-0 


Halibut, broiled 


O CO 


u 


61-39-0 


Mackerel, broiled 


CO 


r 2.6 


56-44-0 


Salmon, canned 


m 
o 


1.8 


45-55-0 


Eoast veal 


■s 


2.7 


71-29-0 


Eoast chicken 


d 


1.9 


73-23-4 


Dried beef 


.2 * 


1.7 


67-33-0 


Boiled mutton 


'32 
II 


2.1 


74-26-0 


Round steak, broiled 


1.9 


48-52-0 


Roast pork 


O 


1.7 


55-45-0 


Tripe 


©1 


2.4 


46-54-0 


Roast lamb 




. 1.8 


41-59-0 


Tenderloin steak 


£- 


r 1.3 


34-66-0 


Roast mutton 


o 


1.1 


33-67-0 


Ham, boiled 


o 


1.2 


29-71-0 


Corned beef, boiled 


i— i 


1.2 


21-79-0 


Tongue 


.2 "* 


1.2 


27-73-0 


Roast beef 


*0Q 


1.2 


46-54-0 


Lamb chop 


II 


1. 


40-60-0 


Roast turkey 


S 


1. 


40-60-0 


Roast duck 


i— 1 


1. 


30-70-0 



* These analyses are based for the greater part upon Bulletin 28, 
Office of Experiment Stations, U. S. Department of Agriculture. 
The values of cooked foods are necessarily approximate and allow- 
ance should be made for dressings, sauces, etc., especially the fat 
in which foods are cooked. 

100 



MEASURED FEEDING 

Table III. Quantities of Food Necessary to Yield 100 

Calories, with the Proportion of Proteid, Fat 

and Carbohydrate — Continued 





Fish and Meat 














Calories 








Oz. 


P. F. Ch. 


Sausage 


two-thirds 


.7 


20-78-2 


Bacon 


1 slice 




.5 


13-87-0 


Salt pork 


1 in sq 




.5 


4-96-0 


Clams 


12 to 16 




4.7 


56-8-36 


Oysters 


twelve 




7. 


49-22-29 


Sardines 


four 




1.3 


34-66-0 


Lobster 


3 h tbsp 




4.1 


78-20-2 


Scallops 


2 h tbsp 




2.5 


80-1-19 


Lean part lamb 


chop weighs 1 


oz. 






Fish and meat 


vary in value according 
Dairy Products 


to fat 


present. 


Butter 


1 pat 




.4 


1-99-0 


Cheese: 










American 


1 cu in 




.9 


25-73-2 


Cottage 


2 h tbsp 




.1 


76-8-16 


Cream, full 


1 cu in 




.9 


25-73-2 


Neufchatel 


1 cu in 




.9 


22-76-2 


Pineapple 


1 cu in 




.9 


25-73-2 


Roquefort 


1 cu in 




.9 


25-73-2 


Swiss 


1 cu in 

Soups 




.9 


25-74-1 


Cream : 










Asparagus 






r 3.9 


12-70-18 


Celery 




N 


3.8 


10-73-17 


Corn 




88 


3.2 


12-43-45 


Pea 




V £ ^ 


3.2 


16-48-36 


Tomato 




CO ^ 


3.5 


10-70-20 


Clam choMder 




o 


3.8 


20-38-42 


Fish chowder 






3.9 


34-35-31 


Thick: 










Bean 




N 


r 5.4 


20-20-60 


Chicken 




i— i - 
«3 A 


6. 


72-12-16 


Split pea 
Meat stew 






6. 


26-2-72 




© -4-3 

01 o 


4.3 


23-49-28 


Oyster stew 




•+J 


5. 


23-57-20 


Clear: 




Kl 






Bouillon 




^l r 


32. 


84-8-8 


Consomme 




S2 J 


29. 


85-0-15 


Vegetable 




* 1 


25. 


85-0-15 



101 



NUTRITION AND GROWTH IN CHILDREN 



Table III. Quantities of Food Necessary to Yield 100 

Calobies, with the Proportion of Proteid Fat 

and Carbohydrate— Continued 



Vegetables 



Asparagus : 
Fresh 
Cooked 
Beans : 
Baked 
Lima, fresh 
String 
Beets 
Cabbage 
Carrots 
Cauliflower 
Celery 
Corn: 
Canned 
Green 
Cucumber 
Lettuce 
Mushrooms 
Onions 
Parsnips 
Peas: 
Green 
Canned 
Potatoes : 
Sweet, baked 
White, baked 
Rhubarb : 
Stewed 
Spinach, boiled 
Squash 
Succotash 
Tomatoes : 
Canned 
Fresh 
Turnips 



Corn flakes 
Cream of wheat 
Farina 
Grape nuts 
Hominy 
Indian meal 







Calories 




Oz. 


P. F. Ch. 


20 stalks 


15.9 


32-8-60 


7 h tbsp 


7. 


34-6-60 


1 tbsp 


2.7 


21-18-61 


2 tbsp 


4.4 


21-4-75 


10 tbsp 


8.5 


22-7-71 


6 h tbsp 


7.7 


14-2-84 


60 h tbsp 


11. 


20-8-72 


4 h tbsp 


5.S 


10-5-85 


24 h tbsp 


11.5 


23-15-62 


1 bunch 


19. 


24-5-71 


2 h tbsp 


3.5 


11-11-78 


2 ears 


3.5 


13-10-77 


2 large 


20. 


18-10-72 


2 large heads 


18. 


25-14-61 


8 large 


7.6 


31-8-61 


4 h tbsp 


7.2 


13-6-81 


5 h tbsp 


5.8 


10-7-83 


4 h tbsp 


3.5 


28-4-68 


4 h tbsp 


4.4 


25-3-72 


% aver 


1.5 


6-9-85 


1 aver 


3.6 


11-1-88 


2 h tbsp 


1.7 


1-2-97 


4 h tbsp 


21. 


12-8-80 


4 h tbsp 


7.4 


12-5-83 


3 h tbsp 


3.5 


15-9-76 


12 h tbsp 


15.6 


21-8-71 


4 aver 


15.5 


16-16-68 


6 h tbsp 


8.7 


13-4-83 


Cereals 






10 h tbsp 


1. 


6-4-90 


4 h tbsp 


6. 


12-3-85 


4 h tbsp 


6. 


12-4-84 


2 h tbsp 


1. 


13-2-85 


S h tbsp 


4.2 


11-2-87 


S h tbsp 


6. 


10-5-85 


102 










MEASURED FEEDING 



Table III. Quantities of Food Necessaby to Yield 100 

Calobies, with the Pbopobtion of Pboteid, Fat 

and Caebohydbate — Continued 

Cereals 









Calories 


Macaroni : 




Oz. 


P. F. Ch. 


Boiled 


4 h tbsp 


4. 


15-2-83 


Oatmeal 


4 h tbsp 


5.0 


17-16-67 


Puffed rice 


10 h tbsp 


1. 


9-1-90 


Ptice, boiled 


4 h tbsp 


3.1 


10-1-89 


Shredded wheat 


one 
Bread 


.9 


13-5-82 


White 


3x3V>xl in 


1.3 


14-6-80 


Whole wheat 


2y 2 x2%x% in 


1.4 


16-3-81 


Corn 


2x2x1 in 


1.2 


10-24-66 


Biscuit 


one 


1.3 


11-27-62 


Roll, Vienna 


one 


1.3 


12-7-81 


Zwieback 


3 pieces 


.8 


9-21-70 


Pilot 


% cracker 
Crackers 


.9 


11-12-77 


Boston 


one 


.9 


11-19-70 


Educator 


twelve 


1. 


40-3-57 


Graham 


two 


.8 


9-20-71 


Oatmeal 


se\en 


.8 


11-24-65 


Oyster 


twenty-four 


.8 


7-24-69 


Saltines 


six 


.8 


10-26-64 


Uneedaa 


four 
Fruits {fresh) 


.9 


9-20-71 


Apple 


1 large 


7.3 


3-7-90 


Banana 


1 large 


5.5 


5-5-90 


Blackberries 


4 h tbsp 


6.1 


9-16-75 


Canteloupe 


one-half 


8.6 


6-0-94 


Grapefruit 


one-half 


11.4 


3-12-85 


Grapes, Concord 


1 bunch 


4.8 


5-15-80 


Lemon 


1 large 


7.6 


9-14-77 


Orange 


1 large 


9.4 


7-2-91 


Peach 


3 aver 


10.5 


6-3-91 


Pear 


1 large 


6.3 


4-7-89 


Pineapple 


2 slices 


8.2 


4-6-90 


Raspberries 


9 h tbsp 


5.3 


10-14-76 


Strawberries 


10 h tbsp 


9. 


10-15-75 


Watermelon 




11.7 


5-6-89 



103 



NUTRITION AND GROWTH IN CHILDREN 



Table III. Quantities of Food Necessary to Yield 100 

Calobies, with the Proportion of Proteid, Fat 

and Carbohydrate — Continued 

Fruits (dried), edible portion 









Calories 






Oz. 


P. F. Oh. 


Dates 


3 large 


1. 


2-7-91 


Figs 


1 large 


1.1 


5-0-95 


Prunes 


3 large 


1.4 


3-0-97 


Raisins 


10 large 
Desserts 


1.1 


3-9-88 


Cakes : 








Sponge 


2x2x1 in 


.9 


11-19-70 


Chocolate layer 


2x1 y 2 xl in 


1. 


7-22-71 


Frosted 


2x11^x1 in 


1. 


6-22-72 


Gingerbread 


2x2x1 in 


1.2 


8-22-70 


Lady fingers 


two 


.9 


10-12-78 


Macaroons 


two 


.8 


6-33-61 


Cookies 


two 


.8 


7-22-71 


Chocolate eclair 


V 2 small 


.8 


4-33-63 


Doughnut 

pipa . 


2/3 


.8 


6-45-49 


Custard 


1/5 of a quar 


1.9 


9-32-59 


Lemon 


1/5 of a quar 


1.4 


6-36-58 


Squash 


1/5 of a quar 


1.9 


10-25-65 


Apple 


1/6 of a quar 


1.6 


3-41-56 


Mince 


1/6 of a quar 


1.2 


8-38-54 


Puddings : 








Bread 


1 h tbsp 


1.6 


10-20-70 


Baked custard 


2 h tbsp 


2.6 


17-37-46 


Rice custard 


2 h tbsp 


2.7 


8-13-79 


Apple tapioca 


2 h tbsp 


3. 


1-1-98 


Indian 


1 h tbsp 


2. 


12-25-63 


Ice Cream 


1 h tbsp 
Siceets 


2. 


6-55-39 


Cocoa 


4 h ts 


.7 


17-53-30 


Chocolate 


V-2 sq 


.56 


8-72-20 


Fruit sauces 


2 tbsp 


2. 


1-3-96 


Jellies, all 


1 tbsp 


1. 


1-0-99 


Marmalade 


1 tbsp 


1. 


1-2-97 


Honey 


1 tbsp 


1. 


1-0-99 


Sugar : 








Granulated 


4 ts 


.9 


0-0-100 


Powdered 


4 h ts 


.9 


0-0-100 


Cube 


4 lumps 


.9 


0-0-100 


Domino 


6 small or 








3 large 


.9 


0-0-100 


Maple 


4 ts 


1. 


1-0-99 


Maple Syrup 


1 tbsp 

104 


1.2 


0-0-100 






MEASURED FEEDING 



Table III. Quantities of Food Necessary to Yield 100 

Calories, with the Proportion of Proteid, Fat 

and Carbohydrate — Continued 



Nuts 









Calories 






Oz. 


P. F. Ch. 


Almonds 


eight 


.5 


13-77-10 


Brazil 


three 


.5 


10-86-4 


Chestnuts, Italian 


seven 


1.5 


10-20-70 


Filberts 


ten 


.5 


9-84-7 


Peanuts 


13 double 


.6 


20-63-17 


Pecans 


eight 


.5 


6-87-7 


Walnuts, English 


ten 
Miscellaneous 


.5 


10-83-7 


Olives, green 


seven 


1.6 


1-84-15 


Alcohol 




.5 




Foods Used for Infants and 


in Illness 










Calories 




Cal. tooz. 


Oz. 


P. F. Ch. 


Albumin water 








1 white to 8 oz 


3.5 


28. 


100-0-0 


Barley Water 








1 oz to qt 








(.13 .07 2.44) 


3.1 


32. 


4-6-90 


Barley gruel 








2 oz to qt 








(.27 .15 4.89) 


6.2 


16. 


4-6-90 


Rolled oats water 








1 oz to qt 








(.26 .14 1.67) 


2.5 


40. 


12-14-74 


Polled oats gruel 








2 oz to qt 








(.52 .28 3.34) 


5. 


20. 


12-14-74 


Beef broth 


1.1 


88. 


100-0-0 


Chicken broth 


1. 


100. 


30-55-15 


Beef juice: 








Cold process 


14. 


7. 


100-0-0 


Warm process 


19. 


5.3 


78-22-0 


Orange juice 


14. 


7. 


0-0-100 


Olive oil 


25,0. 


.4 


0-100-0 


Malt soup (Keller's) 






(12 1.2 12.1) 


20. 


5. 


12-16-72 


Human milk 








(1.25 3.5 7.0) 


20. 


5. 


8-52-40 



105 



NUTRITION AND GROWTH IN CHILDREN 



Table III. Quantities of Food Necessary to 
Calories, with the Proportion of Pboteid 
and Carbohydrate — Continued 
Foods Used for Infants and in Illness 

Oz. 
5. 



4.5 



Cow's milk Cal. tooz 


(3.5 4.0 4.5) 


20." 


Eich milk 




(3.5 5.0 4.5) 


22. 


Cream : 




Top milk, 40% 




(2.2 40 3) 


100. 


Top milk, 16% 




(3.25 16 4.05) 


50. 


Top milk, 7% 




(3.5 7 4.5) 


27. 


Skimmed milk 




(3.6 1.8 4.5) 


14. 


Butter milk 




(3.6 .5 4.06) 


11. 


Condensed milk ( Eagl< 


i 


brand ) 




(8.43 6.94 50.69)100. 


Six parts water 




(1.20 .99 7.23) 


13. 


Nine parts water 




(.84 .69 5.1) 


9.5 


Whey 




From whole milk 




(.94 .96 5.49) 


10.5 


Eiweismilch 




(13-25-15) 


12. 



Koumyss : 

From cow's milk 
(2.66 1.83 4.09) 12.5 
Sugar, gran 4 ts: 

Powdered, 4 h ts 
Milk sugar 
Dextri maltos, 3 h ts 
Mellen's food, 3 h ts 
Malted milk, 3 h ts 
Wheat or barley flour 
Apple sauce, 2 tbsp 
Prune sauce, 3 med w juice 
Scraped beef 
Egg, one large: 

White, seven 

Yolk, two 
Zwieback, three 



Yield 100 
Fat 



Calories 
P. F. Ch. 
20-52-28 

18-59-23 



1. 


2-95-3 


2. 


7-84-9 


3.75 


15-66-19 


7. 


30-33-37 


9. 


41-13-46 


1. 


11-20-69 


7.5 


11-20-69 


10.75 


11-20-69 


9.5 


11-25-64 


8.5 


30-56-14 


8. 


24-38-38 


.86 


0-0-100 


.86 


0-0-100 


.9 


0-0-100 


.9 


0-0-100 


.9 


12-6-82 


.83 


15-19-66 


1. 


12-3-85 


2.2 


1-4-95 


3.8 


2-1-97 


2. 


61-39-0 


2.1 


36-64-0 


6.4 


97-3-0 


.94 


17-83-0 


.8 


9-21-70 



106 



CHAPTER XI 

DIET AND FOOD HABITS 

It is universally recognized that diet is an 
important factor in nutrition. What is not suf- 
ficiently recognized is that other factors of 
equal importance must be controlled before mal- 
nutrition can be removed and proper growth 
established. Attention must be given, not only 
to the character of the foods selected, but also 
to the fuel value of the amount taken, and to 
the child's habits of eating. 

The problem of an " optimum" or ideal diet 
is receiving the attention of the chemist, the 
biologist, and the anatomist, but it has not yet 
been discovered just what amount of each food 
element is needed by the growing child. This 
is especially true of the vitamins, and even 
were it known how much of these is needed, it 
would still be necessary to determine under 
what conditions they are best absorbed. Few 
investigations, other than clinical research, 
have yet been made to determine the influence 
of physical defects, fatigue, and toxins on ab- 
sorption. Emotional reactions, such as fear, 

107 



NUTRITION AND GROWTH IN CHILDREN 

anger, hurry, worry, and stress must also be 
taken into account as affecting the child's power 
of assimilation. 

If the body is not in these respects in a con- 
dition favorable for absorption, the diet may be 
an " optimum" one, the amount taken double or 
treble that necessary for growth, yet the child's 
weight will remain stationary, or may even de- 
crease, for weeks and months at a time. 

Recent investigations have demonstrated the 
harmful effect of the too exclusive use of de- 
germinated foods such as milled flour, polished 
rice, and artificially prepared products in caus- 
ing a deficiency of valuable constituents. New 
evidence of this kind must not be neglected, but 
there is no cause for alarm except where good 
milk cannot be obtained in sufficient quantity to 
supply the deficiency. Our present knowledge 
indicates that if a child takes a sufficient amount 
of the usual foods of the average American ta- 
ble, including a pint of milk a day, he will have 
all the dietary essentials for proper growth. 
It is a safe rule to require the child to take a 
little of each food provided for the family table 
in order that he may not get the idea that he 
cannot eat this or that, and thus be deprived of 
an essential food element. 

The 48-hour record that is used to check the 
108 



DIET AND FOOD HABITS 

total amount of food taken is also the best 
guide to possible food deficiencies and to faulty 
food habits. In checking and correcting many 
thousands of diet lists we have found the chief 
errors to be: 

1. The omission of cereals and milk 

2. The use of tea and coffee 

3. The taking of sweets between meals 

4. Irregular meals, and irregular amounts at the 
different meals 

5. Insufficient 24-hour amount of food 

The Balanced Diet. — It is not necessary to 
provide an unusual or peculiar diet for the mal- 
nourished child. Elaborate dishes and delica- 
cies intended to tempt the appetite are of less 
value than plain wholesome food in proper 
amounts. Catering to childish whims is one of 
the chief causes of the surprisingly large per- 
centage of malnutrition found among the chil- 
dren of the rich. The child should be allowed 
to experience the healthy satisfaction of clear- 
ing his plate and asking for more. Experience 
shows, fortunately, that children thrive on sim- 
ple and comparatively inexpensive foods — milk 
and milk products, whole cereals, corn, rye, and 
whole wheat bread, fish and the cheaper cuts 
of meat, such vegetables as potatoes, onions, 

109 



NUTRITION AND GROWTH IN CHILDREN 

carrots, and greens, and fruits and berries as 
they are available. 

In normal health the question of a balanced 
diet, or the proper proportion of proteid, fat, 
carbohydrate, and salts, needs attention only in 
a general way, because this is largely regulated 
by taste and custom. For example, bread, 
which contains proteid and carbohydrate, re- 
quires butter (fat) to make it palatable; meat, 
composed of fat and proteid, requires potato 
(carbohydrate) to please the taste. The cus- 
tomary combination of bread and butter, meat 
and potato, bread and milk, represents physio- 
logical needs which taste recognizes and con- 
trols. Mineral salts are secured through milk, 
fruit, and the green vegetables. 

Essential Foods. — Certain foods are, how- 
ever, essential to proper growth, irrespective of 
the child's taste. If milk and cereals are 
omitted from the diet, it is difficult to keep the 
daily total high enough for continued gain. 
Children should have food of high caloric value, 
and milk supplies this need as well as providing 
all the required food elements. Every child 
should have at least a pint of milk a day 
throughout the period of growth, and for the 
undernourished a quart is better. When the 
taste of plain milk is not agreeable, the milk 

110 



DIET AND FOOD HABITS 



may be flavored with a little malt or cane sugar, 
or taken in the form of cocoa, with bread, 
crackers, or cereal, in the sauce for vegetables, 









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Figure 19. cereal omitted 

Bertha's mother feared oatmeal was too "heating" and omitted It 
from Bertha's diet the first week in June. The chart shows a con- 
sequent loss in weight which was immediately regained 
when the cereal was replaced in the diet. 

or in purees and thick soups. When used in 
cooking it is useful in increasing the nutritive 
value of various dishes. 
Proteid is an essential food constituent, as 
111 



NUTRITION AND GROWTH IN CHILDREN 

new cells are produced by proteid only. The 
tendency, however, even among the poor, is to 
take too much rather than too little proteid. 
Young children may be given beef juice as an 
appetizer, and a small amount of meat will 
stimulate growth, but at no age is the excessive 
use of meat either economical or wholesome. 
Proteid is found in many other substances, in- 
cluding milk, eggs, fish, and certain vegetables. 1 

The vitamin Water-soluble B is present in 
so many articles of food that it is rarely insuf- 
ficient in the American diet. Fat-soluble A, 
which is less widely distributed, is present in 
milk, butter, cream, eggs, animal fat, and the 
leafy vegetables. 2 

A word of caution is needed against the ex- 
cessive use of fruits and vegetables in the effort 
to supply vitamins in the child's diet. These 
are foods of low caloric value, which, although 
supplying essential food factors, may leave the 
child undernourished due to an insufficient 24- 
hour amount. It is better to safeguard the child 
in this respect by the use of milk, which contains 
all the necessary elements and is a food of high 
fuel value. 

1 See Table of Food Values with percentage of proteid, 
fat, and carbohydrate on pp. 100-106. 

2 See Table of Accessory Food Factors, p. 177. 

112 






DIET AND FOOD HABITS 

The coarse vegetables are valuable for fiber 
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Figure 20. candy habit 

Marion ate a light breakfast, and when she became hungry in the 
middle of the morning, satisfied her appetite with candy. Thia 
spoiled her appetite fo. the midday meal. Becoming: hungry again 
in the afternoon, she ate more candy. The chart shows her prompt 
gain after omitting the candy and eating a proper amount of 
wbolesome food — an increase of 7^4 pounds in three weeks. 

trated foods. Potatoes are especially whole- 
some, and should be eaten at least once a day, 
preferably at the midday meal. They can be 
prepared in many ways, and are one of the best 

113 



NUTRITION AND GROWTH IN CHILDREN 

vehicles for the consumption of milk, cream, 
and butter. 

Sweets. — Sweets are not harmful if taken at 
proper times and in moderate amounts. There 
is no evidence that sugar is injurious in its ef- 
fects provided it is diluted and balanced by 
proteid and other foods. A few pieces of candy 
taken as a dessert will add to the number 
of calories without impairing the digestion. 
Candy is clear sugar, however, and when taken 
on an empty stomach acts as an irritant, caus- 
ing indigestion and consequent loss of appetite. 
The taking of too much sugar leads to a crav- 
ing for sweets and a disregard for the natural 
flavor of other wholesome foods. 

Liquids and Mastication. — The child needs 
two quarts of liquids a day, and therefore 
should drink plenty of water, which may be 
cooled but should never be iced. This may be 
taken before and after meals, and during the 
meal, provided there is no food in the mouth at 
the time. 

Food should be chewed as long as there is 
taste in it, and should be moistened by the nat- 
ural secretions of the mouth, which aid diges- 
tion. The habit of washing down food with 
liquids leads to imperfect assimilation, and 
where this practice has been established, all 

114 



DIET AND FOOD HABITS 

liquids shoud be placed out of the child's reach 
until the habit is broken. 



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FlGUBE 21. FAST EATING 

Charles, at the age of eight, was underweight nearly 10 pounds. At 

54 pounds he stopped gaining. Such a failure to gain Indicates a 

relative loss, as weight, should Increase steadily during childhood. 

The cause in this case was fast eating. When Charles was 

induced to eat slowly, his weight increased rapidly. 

Milk is a food, and therefore should not be 
used to quench thirst. It should be taken 
slowly, preferably with a spoon; for example, 
on cereal or in the form of bread and milk. 

115 



NUTRITION AND GROWTH IN CHILDREN 

Growing children should not be allowed to drink 
tea or coffee. 

Fast Eating. — Every meal should take at 
least 20 minutes by the clock, and the child 
should sit through to the end with the rest of 
the family. The pernicious habit of fast eating 
is one of the most difficult to correct, and where 
a child has formed the habit, it may be neces- 
sary to begin all over again and teach him how 
to eat, just as one teaches an infant. One help- 
ful device is to give him a small fork and spoon, 
such as an oyster fork or an after-dinner coffee 
spoon, and thus cut down automatically the 
amount of food he can put into his mouth at one 
time. The child will often be amused and inter- 
ested by these special utensils of his own, but if 
such measures are not successful, it may be 
necessary for some other person to feed him 
for a sufficient time to overcome the habit. 

The Family Table. — The question is often 
asked whether it is better that a child should 
eat alone in the nursery or have his meals with 
the other members of the family. Children 
need companionship at their meals as at other 
times, and there is an educational value in the 
ordinary associations of well regulated family 
life which should not be overlooked. A child 
will imitate an older boy or girl, and thus learn 

116 



DIET AND FOOD HABITS 

to eat new kinds and quantities of food that 
would be refused under other conditions. 

Loss of Appetite — Its Cause and Its Cure. — 
If a growing child has no desire to eat, there is 
always an adequate cause for his lack of ap- 
petite. The small appetite is often a provision 
of nature to prevent overeating when tired, thus 
causing indigestion. "Too tired to eat" is a 
frequent condition with malnourished children. 
Another cause of poor appetite is irregular eat- 
ing. For example, a small breakfast and a 
heavy dinner is like giving an infant two ounces 
at one feeding and twelve at the next. Irregular 
intervals between meals, and the practice of 
nibbling food all through the day interferes 
with the appetite for the next meal. The serv- 
ing of too large a portion will sometimes cause 
a child to eat less than he would if a smaller 
amount were offered. 

The state of the child's mind may prevent 
his eating properly. Many children would 
rather play than eat, and, with minds intent 
upon their games, will run from the table be- 
fore they have taken sufficient food. Unhappi- 
ness and worry, often unsuspected by parents, 
are also causes of a loss of appetite. While 
the parents should know what is best for the 
child, and should see that their program is car- 

117 



NUTRITION AND GROWTH IN CHILDREN 

ried out, the joy and satisfaction of the meal 
should not be spoiled by constant nagging. 

A large group of "no appetite" cases are 
caused by the effect of drugs. The most com- 
mon of these is caffein from coffee and tea. A 
third of a cup of tea contains about one grain 
of the drug, as much as is given in an average 
dose for medicinal purposes. Records from 
our clinics in Boston, New York, and Chicago 
show that about 85 per cent of the malnourished 
children treated used tea or coffee or both, one 
or more times each day. 

Among older children there is more trouble 
from nicotine than most parents realize, espe- 
cially among boys and girls who are allowed to 
smoke at the age of sixteen to twenty, before 
their period of growth is complete. The most 
remarkable fact about all these drugs is their 
baneful effect upon growing tissue, while con- 
siderable amounts can be used in later life with 
no apparent harm. An exception to this latter 
statement must be made in the case of coffee, 
where the aromatic oils are frequently the 
cause of indigestion. 

There are disadvantages arising from the ar- 
rangement of many modern homes, in which 
the kitchen is so far removed from the scene of 
the child's activities that he does not get the 

118 



DIET AND FOOD HABITS 

healthy stimulation of appetite that comes, for 
example, from the odors of baking. If he can 
see and smell food in the process of preparation, 
the desire to taste will naturally follow. This 
is exemplified in camp life where children eat 
plain coarse food with more zest than they have 
for the dainties of the richest home table. The 
gains made in these summer camps are due 
quite as much to the increased food and normal 
associations with other children as they are to 
the air and exercise. 

It is fatal to force feeding when the child is 
not hungry. If he does not feel equal to eating 
a proper amount, his activities should be limited 
so that he will not use up his scant supply of 
energy. He should be restrained from activity 
before breakfast in particular, as inadequate 
breakfasts are more frequently reported in the 
diet lists than insufficient meals at any other 
time. When the child refuses his breakfast he 
should be put to bed, and kept there until his 
appetite returns or the cause is found. It 
should be made certain that this lack of appe- 
tite in the morning is not due to bad air in the 
sleeping room, or to a catarrhal discharge from 
the naso-pharynx during the night. 

Food Aversions. — In the case of undernour- 
ished children, food prejudices, aversion to 

119 



NUTRITION AND GROWTH IN CHILDREN 

form, taste, or smell, or the association of cer- 
tain foods with unpleasant events, may be 
almost insurmountable obstacles in securing 
proper nutrition. Among girls, especially, the 
appetite is fickle, leading them to choose carbo- 
hydrates almost wholly, and to take far too low 
a percentage of proteid and the leafy vegetables 
for proper growth. 

This distaste for certain vegetables can often 
be corrected by a change in the method of pre- 
paring or combining them. A creamed sauce 
will not only add agreeably to their flavor, but 
also enhance their food value. By combining 
peas with carrots, and corn with potatoes or 
beans, the child can be trained to like vegetables 
in increasing variety. With the ordinary 
standard foods it is proper to require the child 
to take a small portion of something which he 
thinks he dislikes in order to rid him of the idea 
that he cannot eat it, but to compel him to make 
a whole meal out of foods for which he has no 
taste is to risk establishing a permanent 
antipathy. 

There is great danger that the child with a 
poor appetite will unconsciously eliminate one 
good food after another, so that, amidst plenty, 
he may come to live, as stated by McCollum, 3 

3 E. V. McCollum, "The Newer Knowledge of Nutrition." 
120 



DIET AND FOOD HABITS 

on a dangerously restricted diet consisting of 
muscle meat, white bread, and potato, with only 
the variety that results from other foods of a 
like nature such as degerminated cereals, sugar, 
and the tuber vegetables. 

Food should never be used as a vehicle for 
medicine. This practice sometimes causes 
aversions that persist throughout life, which 
are all the more serious in their consequences 
because the foods disliked are apt to be those of 
high caloric value. 

There are other food aversions due to the 
idiosyncrasy of the individual in regard to par- 
ticular foods, which must be regarded as cases 
of food poisoning and be treated as such under 
the advice of a physician. For example, some 
children are poisoned by strawberries, eggs, 
lobster, or the proteins of various other foods. 
This condition, which is known as anaphylaxis, 
cannot be traced to its cause in many cases 
without a series of cutaneous food tests. It 
should not be assumed as the basis for the food 
prejudices of the child until such an examina- 
tion has proved it to be the case. 

It is universally recognized that the appear- 
ance and health of an animal depend on the food 
and the care which he receives ; but a child may 
be "dragged out," irritable and fault-finding, 

121 



NUTRITION AND GROWTH IN CHILDREN 

and it is assumed that this is a natural state for 
the growing boy and girl. More progress has 
been made in the feeding of animals than in 
that of man. Regularity, smaller and more 
frequent feedings, enough food without waste, 
and the importance of clearing up at each meal 
what has been provided are recognized stand- 
ards in animal feeding. All these principles 
are equally applicable to the feeding of chil- 
dren. Many parents resent being reminded that 
their children are young animals, but there 
would be less malnutrition if this truth were 
better realized. 






CHAPTER XII 

HEALTH HABITS 

In bringing the undernourished child up to 
his normal weight, attention must be focused, 
not only upon food and food habits, but upon 
such other fundamentals of health as rest, fresh 
air, bathing, and proper clothing. It is neces- 
sary to look into every detail of a child's life 
to find the cause of malnutrition, and except 
where there is a single conspicuous obstacle to 
health, this cause is frequently found to be the 
neglect to establish sound health habits in sim- 
ple but essential matters. 

Dr. Rene Sand of Brussels reports that the 
war has caused at least a year's retardation in 
the growth of children in Belgium. With this 
heavy burden added to the malnutrition already 
present before the war, a condition exists that 
no mere supplying of additional food will cor- 
rect. It can be cured only by special instruc- 
tion in rest and other fundamental health 
habits. 

The subject should be approached in the be- 
lief that nature always makes for health, and 

123 



NUTRITION AND GROWTH IN CHILDREN 

usually succeeds unless there are conditions too 
unfavorable for her to overcome. 

Fresh Air. — In the treatment of malnourished 
children we have found that those who sleep 
on porches or under window tents gain in 
weight faster than those who sleep in a room 
with several windows open. It is of equal im- 
portance that as much time as possible should 
be spent in the open air during the day, and 
the hours of sunlight are particularly desirable. 
This was illustrated in the case of a group of 
12 children, who had been gaining well until 
there came a week of daily storms. These chil- 
dren were in an institution where the ventila- 
tion was as nearly perfect as possible, and in 
their playroom the windows were wide open; 
yet every child stopped gaining, and some be- 
gan to lose because they were not able to be 
actually out of doors. 

Open-air schools were originally intended 
only for children below par, but it is now real- 
ized that conditions which make the sick well 
are favorable for all. It has been found that 
pupils who make rapid gains in weight in open- 
air classes begin to lose as soon as they return 
to the ordinary shut-in type of schoolroom. 
Open-air schools do a further service in reduc- 
ing contagion, which is of importance at all 

124 



HEALTH HABITS 

times, but especially during- such a widespread 
danger as the influenza epidemic of 1918. An 
open-air school observed at that time went 
through the epidemic with scarcely a case 





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Figure 22. bad air 

Esther slept in a room with four other persons with the windows 
closed. She also had the habit of keeping her head under the 
blankets. Her parents were prejudiced against cold air at night, but 
agreed to have the windows open when Esther failed to gain. This 
also induced her to keep her head outside the bed clothing, 
and she soon made a good gain in weight. 



among teachers or pupils, while neighboring 
schools were obliged to close. 

Indoor temperature should not be kept above 
68 or, at most, 70 degrees. Experiments show 

125 



NUTRITION AND GROWTH IN CHILDREN 



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FlGUEE 23. A SO-CALLED "PRE-TUBERCTJLAR" CHILD 



Perry C. was under constant observation at the New England Home 
for Little Wanderers, and his chart illustrates a number of the 
most common causes that affect nutrition. His first failure to gain 
occurred in the week of December 20, and was traced to over- 
indulgence in apples between meals. A barrel that had been sent 
as a holiday gift was left open where he could help himself. By 
eating apples freely he took less of more nourishing foods, and lowt 
one-half pound. January 31 and February 7 he failed to gain 
because of playing with another boy during rest periods. February 
21 was a week when the extra lunches were omitted. The week 
of March 13 it stormed every day, and he could not play outdoors. 
During "apple week," the week when lunches were omitted, and 

that both children and adults fall off in their 
working efficiency as soon as the temperature 

126 



HEALTH HABITS 



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Figure 23. — Continued 

the week of bad weather all others in the class failed to gain for 
the same reason. 

As Perry had made no marked increase over the normal rate of 
gain from Jamiary 24 to April 3, it was decided that his tonsils, 
which were cryptic, might be the disturbing cause. The tonsils 
were removed, but he was kept in bed only two days, and lost five 
pounds. He regained this weight, and continued to gain until 
May 8, when as a result of returning to school he made no gain. 
June 12 shows the effect of overeating at a picnic. July 3 he 
reached normal weight for his height, and was in excellent con- 
dition. Perry's mother had died of tuberculosis. Good nutrition 
is the best safeguard against this disease. 

rises above this point. Another bad condition 
is the dryness of an overheated room, and some 

127 



NUTRITION AND GROWTH IN CHILDREN 

means should be provided for adding moisture 
to the air. Moist air at a low temperature is 
not only more healthful, but far more comforta- 
ble, than dry air at a high temperature. Air 
in motion is better than still air, and electric 
fans and other devices for keeping air in circu- 
lation have a value beyond the immediate com- 
fort they afford. 

It is dangerous to allow a sudden chilling of 
the body, as this lowers the resistance to bac- 
teria which cause various forms of infection. 
But a fear of drafts usually indicates a condi- 
tion of sensitiveness that ought to be looked 
into and corrected. There is no danger from 
open windows at night if protection from a 
direct draft is secured by means of screens or 
by a blanket placed over a chair by the bedside. 
It is not enough that the windows of the sleep- 
ing room should be open, but the air must actu- 
ally circulate. For this reason windows on two 
sides, which permit a cross current, are desira- 
ble. Where the bed is in a corner or an alcove, 
it should be drawn out at night, because several 
hours may otherwise pass before the air about 
the bed is completely changed. 

Drugs Unnecessary. — In many families it is 
still the custom to give a child medicines strong 

128 



HEALTH HABITS 

enough to do injury to an adult. The tempta- 
tion most commonly appears in a supposed need 
for tonics and laxatives. Tonics are rarely 
necessary, and should be given only when there 
is an adequate reason. If the child has a suf- 
ficient variety of food, he will be supplied with 
all the iron and salts he requires. 

Good health habits and proper food make the 
use of laxatives unnecessary. There should be 
a regular time for the bowels to move, at least 
once a day, preferably just after breakfast, 
when the mother should see that the child is 
free from hurry, worry, or nagging. Many 
mothers are so fearful that the child's bowels 
will not move that they continue to give cathar- 
tics when there is no possible need. If the daily 
movement is skipped occasionally, it does not 
necessarily mean harm. 

If a drug has been used and the habit formed, 
the dose should be gradually reduced until the 
habit is entirely broken. The only exception 
that should be made is in a case of acute in- 
digestion, when a tablespoonful of castor oil 
given immediately will remove the undigested 
food and enable the child's digestion to begin 
anew. 

The growing child does not need drugs, all 
129 



NUTRITION AND GROWTH IN CHILDREN 

of which are pernicious when taken habitually. 
There should be an abundance of fruit and 
coarse vegetables in the diet, and a further help 
is the drinking of plenty of water, especially 
before breakfast. 

Care of the Teeth. — Children should be taught 
the use of the toothbrush from their earliest 
years, and at the first signs of decay they should 
be taken to a dentist to have the teeth filled or 
extracted. Even baby teeth can be treated and 
cared for. Infections about the roots interfere 
with growth and if neglected may lead to seri- 
ous complications. 

The Right Kind of Clothing.— The malnour- 
ished child needs more clothing than the well 
child in order to keep the body warm. One of 
the physical signs of malnutrition is cold hands 
and feet, which indicates impaired circulation. 
Extra care should be taken in winter, especially 
when the child sleeps in the open. Blankets or 
newspapers should be put under the mattress, 
because if there is insufficient protection from 
below, no amount of covering will keep the 
child warm. As a matter of routine, a hot- 
water bottle should be put into the bed at night, 
well down in the corner where the feet will not 
touch it unless its warmth is needed. 

During the day there should be only enough 
130 



HEALTH HABITS 

indoor clothing to keep the body warm without 
causing perspiration. Coarse-meshed cotton or 
linen underwear is better than woolen, because 
it permits greater circulation of air ; but in win- 
ter the outer garments should be of wool, and 
woolen stockings should be worn. Sudden 
changes of clothing must be avoided, such as 
the change from heavy to light underwear, and 
from high to low shoes. 

Above all, children's clothing should be com- 
fortable, and adapted to the changing demands 
of play, rest, indoor and outdoor activities. 
Many mothers are too much concerned with ap- 
pearances. Irritating, stiff collars, and clothes 
which the child has to worry about, are a direct 
cause of ill health. Children outgrow their 
clothes faster than may be realized, and tight 
clothing is a cause of serious discomfort. This 
should be specially guarded against in collars 
and shoes. 

Children's shoes should be of the straight 
last type, with ample room for movement of 
the toes so that the joints will not be displaced 
or the circulation impaired. The feet should 
not be allowed to become chilled from damp- 
ness, and rubbers or rubber boots should be 
worn whenever the ground is wet. In unavoida- 
ble cases of wet feet, both stockings and shoes 

131 



NUTRITION AND GROWTH IN CHILDREN 

should be changed without delay. Many serious 
infections result from the neglect of these sim- 
ple precautions. 

Bathing. — The child should be taught to bathe 
properly. He should be thoroughly clean in the 
morning and at night, and the hands should be 
washed carefully before every meal. A cold 
chest bath in the morning serves to harden the 
skin and to protect against changes in tempera- 
ture. A warm neutral bath at night is good, 
and if the child is very tired a hot bath will 
restore the circulation and give rest without 
over- stimulation. 

The malnourished child often has poor circu- 
lation. For this reason swimming in cold water, 
either fresh or salt, should be indulged in with 
great caution. The test is the condition shown 
when he comes out of the water. If he is shiver- 
ing and blue, the bath does him harm. On the 
other hand, if his reaction is good, his skin 
glowing and red, the effect is beneficial. 

Eubbing is of special value in connection with 
all bathing, as it increases the activity of the 
skin, and helps in eliminating waste matter 
from the body. The bath and rub-down which 
have become a regular feature of college ath- 
letics are equally to be recommended for the 
child who comes in perspiring and tired from 

132 



HEALTH HABITS 

his play. In either case a short rest immedi- 
ately after the bath will add to its good effect. 

Habits and Health. — It has been rightly said 
that one who is well at eighteen will probably 
remain well the rest of his life. This is but to 
recognize the influence of habit, and it should 
also be recognized that it is as easy for the 
child to form good health habits as bad. If 
good habits are established in childhood, we 
may be confident that good health will result. 
When a child is not well, irregular and wrong 
habits must be looked for; and, on the other 
hand, where we find healthy, happy children, 
well nourished and up to normal weight, it is 
almost certain that the essentials pf health are 
being maintained by regular meals, regular 
work and play, regular rest and sleep, and 
regular bodily functions. 

The matter of rest and sleep is of so much 
importance that it is treated separately in the 
chapter on overfatigue. 



CHAPTER XIII 

EXERCISE AND RECREATION 



In caring for an undernourished child it is 
easy to forget the importance of exercise and 
play. Children who are not strong naturally 
turn to reading and indoor occupations, and 
thus are deprived of the benefit of outdoor ac- 
tivity. But they need, even more than the well 
child, to spend as many hours of the day as 
possible in the open air. In cold weather they 
should play games with sufficient activity to 
keep them warm, but at all times they should be 
guarded carefully against overfatigue. 

Training in Play. — There is wonderful train- 
ing for the powers of the growing child in play. 
Free play is constructive, and calls into opera- 
tion the various mental and physical capacities. 
Children should be encouraged to work out their 
games in their own way without too close or too 
constant supervision by adults. In this way 
they learn to discipline themselves and one an- 
other. During the early years interest centers 
in imitating the activities of older persons, but 
at the age of seven or eight the spirit of com- 

134 



. 



EXERCISE AND RECREATION 

petition develops, and foundations are laid for 
association and team play. 

In the World War it was shown that the 
strategy worked out in games was adapted to 
the serious purpose of war maneuvers. The 
play of the boy became the work of the man, 
and some of the best achievements were made by 
young athletes of trained eye and muscle but 
with no previous military experience. 

Nothing is more pathetic than the child who 
has never learned to play. Many of the nervous 
breakdowns of later life occur because men and 
women who failed to form the habit of play in 
childhood pursue their work intensely without 
recognizing the need for adequate recreation 
and exercise. The habit of play is a permanent 
safeguard to health. 

The Need of Moderation. — The danger in 
play for the undernourished child is that he will 
engage in games beyond his strength, or indulge 
in them for too long a time without rest. It is 
better for him to begin with simple and easy 
games, and gradually work up to those which 
make greater demands upon him. A boy who 
is underweight should not take part in tourna- 
ments or in such strenuous games as football, 
wherein much endurance is required. Running 
races should also be avoided, and bicycling 

135 



NUTRITION AND GROWTH IN CHILDREN 

should be limited to short rides without heavy- 
grades, 

Skating, coasting, sailing, canoeing, baseball, 
tennis — if the time is limited in each case to 
the child's endurance — are all beneficial and 
productive of growth. Cross-country walking 
is an excellent form of exercise, bringing many- 
muscles into service. The hard pavement of 
city streets, however, results in a monotonous 
repetition of the same steps, thus exercising 
fewer muscles and causing early fatigue. 
Nurse maids often allow a child of pre-school 
age to exceed his strength in this way, and thus 
cause serious harm. 

In general, the underweight child should 
avoid competitive games and should be encour- 
aged to turn to sports requiring skill rather 
than strength. 

Gymnasium work is not to be recommended 
for underweight children, and is never a desira- 
ble substitute for play in the open air. For 
older boys and girls formal gymnastics and 
rhythmic exercises are useful as a means of 
securing poise and control, and provide a source 
of body development during the seasons when 
the opportunity for outdoor sports is limited. 
Dancing, especially folk-dancing and the forms 
that bring about a higher degree of muscular 

136 



EXERCISE AND RECREATION 

control, may be safely indulged in with modera- 
tion. 

All forms of exercise should be made an edu- 
cation as well as a recreation. There is always 
a right and a wrong way to do things. One can 
learn to climb a mountain, "taking it easy," 
with less fatigue than will follow a shorter 
climb taken impetuously and without proper 
rests. The field contests outlined by the Boy 
and Girl Scouts offering opportunity for plan- 
ning and invention are particularly suitable for 
underweight children because they require less 
physical energy than ordinary sports. 

Corrective Exercises. — There has been a tend- 
ency to over-rate the importance of corrective 
exercises. It should be recognized that most 
cases of bad posture are due to the general 
weakness of a body with too little weight to 
support its height. Where this condition exists, 
the first need is to start the child on a program 
that will bring him up to his normal weight, 
when it will be found that as weight increases, 
the posture improves. 

Where formal exercises are needed to correct 
wrong postural habits, or to remedy deformi- 
ties, it should be made certain that the child 
takes extra rest periods to offset the fatigue of 
the exercises. , But where the postural defects 

137 



NUTRITION AND GROWTH IN CHILDREN 

are due to overfatigue and underweight, the 
extra strain of corrective exercises will simply 
add to his burden and aggravate his condition. 
Here, as elsewhere, any constant expenditure 
of energy that is greater than the amount pro- 
duced can only result in lowered vitality and 
failure to attain the object sought. 

After the child has gained normal weight and 
his muscles have recovered tone, then corrective 
exercises are of great benefit. 

Indoor Amusements. — The movie and theater 
habits are unsuitable forms of entertainment 
for the growing child on account of the bad air, 
danger of eye strain, over-stimulation of the 
nervous system, and fatigue from prolonged 
attention. 

Reading and table games afford recreation 
without bodily fatigue, and are a valuable alter- 
native to physical activity. There is danger of 
excess even here, however, and neither games 
nor books should be made the excuse for late 
hours. Reading is not resting, and the child 
should not be allowed to read when lying down. 
Instead of bringing rest and repose this habit 
strains the eye muscles and stimulates nervous 
reactions. 

A Health Program for the Summer. — Sum- 
mer time is especially favorable for physical 

138 



EXERCISE AND RECREATION 

growth, and the best season in which to start a 
program to bring the malnourished child up to 
his normal weight. Freedom from the strain 
of schoolwork and many other conditions that 
cause overfatigue, together with the greater op- 
portunity for outdoor life and more varied diet, 
result in height and weight gains beyond those 
of any other time of the year. Porter has shown 
by the measurements of thousands of Boston 
school children that two-thirds of the gain in 
weight for the year is accomplished from June 
to January. 1 

During the summer season it should be possi- 
ble for the undernourished child to spend prac- 
tically all his time out of doors. Arrangements 
for sleeping out can easily be made. If there is 
no available porch, a small shelter tent can be 
erected and equipped in the yard, or a camp can 
be organized in a vacant lot within reach of the 
home. 

Vacation trips to the mountains, the shore, 
or the country bring new opportunities for ex- 
ercise in the open air, and develop an interest in 
new forms of sport. When longer vacations are 
not possible, a day's outing, or even an after- 

1 W. T. Porter, "The Seasonal Variation in the Growth 
of Boston School Children ," American Journal of Physiol- 
ogy, Vol. 52, No. 1, pp. 121-131, May, 1920. 

139 



NUTRITION AND GROWTH IN CHILDREN 

noon's walk in the country, can be made an oc- 
casion for real refreshment if it is taken in a 
holiday spirit, with the children's interest di- 
rected into new channels. Eating out of doors 
is always an aid to appetite, and, if a further 
excursion is not possible, a porch picnic will 
prove to be a pleasant break from the indoor 
routine. 

The element of enjoyment is necessary for 
the best results from any of these forms of 
recreation, just as it is the spirit of play in 
games and sports that makes them more bene- 
ficial to the participant than formal exercises 
and gymnastics. 

The Benefits of the Summer Camp. — Even a 
brief stay in a well organized summer camp is 
a valuable experience, and may be the means of 
breaking up bad food and health habits, and 
giving the child a new interest in his own health. 
The temporary separation from home and fam- 
ily is beneficial in introducing the child to a 
larger world in which his comfort will largely 
depend on his own efforts. The "only child" 
who has suffered from the excessive care of a 
too indulgent home has a fear of independent 
action which camp life quickly removes. He 
soon learns to "paddle his own canoe" and if 
he finds himself lacking in the vigor required 

140 



EXERCISE AND RECREATION 

for the hikes or sports of his mates, he will at 
once begin to take a keen interest in his physi- 
cal development. 



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CTi ss gain 51)0% 







Figure 24. gain at a girls' camp 

This chart shows the average gain of a group of 30 girls at the 
Arden Shore class uf the Elizabeth MeCormiek Memorial Fund, 
Chicago, maintained for those who apply for working certificates 
but are not up to normal weight. The girls were put on our 
nutrition program, and their activities were regulated according to 
their Individual weight charts. The group gain of 650 per cent of 
the average rate of growth illustrates the results that can be 
obtained by such a program without additional expense for food. 



Here, too, he learns what real hunger means, 
and has to do his share of the necessary tasks 
before his appetite is satisfied. A boy or girl 

141 



NUTRITION AND GROWTH IN CHILDREN 

who spends even a fortnight in direct relation 
with the necessities of life, taking part in the 
preparation of food and the provision of shel- 
ter and warmth, has a different outlook ever 
after. 

Leadership in the camp personnel is of great 
importance in bringing the child under the in- 
fluence of high ideals of right living. But of 
hardly less importance is the proper equipment 
of the camp with scales, and the recognition of 
periodic weighing as the surest test of the 
child's condition. The nutrition program, with 
its alternations of activity and rest, with regular 
hours for meals and lunches, can he easily 
adapted to the camp schedule, and the child's 
gain or loss in weight should be the basis on 
which is determined his fitness to take part in 
the various features of the camp program. 

Athletics for the Older Boy and Girl. — Phys- 
ical training means such mastery and control 
of the body that it will execute the will and carry 
out the mind's ideals. When a boy learns to 
run, swim, or play any organized game he is ac- 
quiring that confidence, independence, and self- 
control which make for health, and which will 
stand him in good stead in his future life. The 
increased participation of girls in physical 
games and sports argues well, not only for 

142 



EXERCISE AND RECREATION 

their own happiness, but for the welfare of the 
families they will later have in charge. 

Young people when they come to a certain 
age tend to assume more and more responsi- 
bility for their own actions, and this is the time 
when they should begin to take a personal in- 
terest in their health. The spur of "making 
the team," or the aim to excel in classwork, may 
be the means of first bringing home to the young 
student the necessity of conserving both his 
nervous strength and his physical powers. 

The student should never come to a period of 
study tired out by physical exercise, nor should 
a person who is exhausted from mental effort 
turn at once to severe physical exertion with- 
out rest. There is a curious notion that physi- 
cal and mental fatigue are quite separate and 
distinct, and that one in some way relieves the 
other. We have only a limited amount of 
energy, and if it is spent in one way it is not 
available in another. It is advantageous to 
change from one form of activity to the other, 
but if the point of fatigue has been reached, 
rest is necessary before further effort, even in 
a new direction, will be really productive. 

A student who is trying to excel along mental 
lines should avoid the strain of trying to excel 
physically at the same time, although he needs 

143 



NUTEITION AND GROWTH IN CHILDREN 

regular exercise and general physical training. 
A boy who tries to train for football, baseball, 
and track, one after the other, will grow stale 
and excel in nothing except at the risk of per- 
manent physical or nervous injury. 

All training, whether mental or physical, 
should stop before the point of overfatigue. 

Health in Industry and Business. — A thorough 
physical examination at the entrance to every 
form of organized employment would prevent 
many later failures and breakdowns. For the 
young person who starts his career with the 
handicap of underweight, permanent success is 
unlikely unless he takes steps to remedy the 
condition promptly. The proper program is 
the same as that outlined for the malnourished 
child with such adjustment as may be necessary 
to meet the conditions of his particular job. 

All young people who are employed indoors 
should make it a point to follow some outdoor 
game or sport all the year round, and the Sat- 
urday half -holiday, and Sunday as far as possi- 
ble, should be spent in the open. A "vacation" 
thus taken systematically throughout the year 
will do more to promote health than a single 
break of a few weeks or months annually, with 
a return to bad habits of daily living. 

The natural ambition of the young should be 
144 



EXERCISE AND RECREATION 

encouraged. Although there is danger in over- 
work, there is also danger in underwork and in 
the dullness that comes from under develop- 
ment of one's powers. It is not work that kills, 
but overwork complicated by friction, worry, 
and poor hygiene. To offset such conditions 
proper rest and recreation are a necessity. 
Recreation that is derived from physical exer- 
cise is better than the passive entertainment of 
the theater or the movies, or even of the bleach- 
ers at a ball game. 

Indoor exercise consisting of five or ten min- 
utes of "setting up" or stretching exercises 
daily will keep the muscles from becoming soft 
and flabby. Unaccustomed exercise causes stiff- 
ness and lameness, and the body can be kept in 
trim only by steady exercise at regular intervals. 

The extent to which adults use exercise and 
play in their own lives makes it easier for the 
child to start right, and tends to raise the stand- 
ards of health for all. Parents who share in 
the sports and games of their children will come 
to a better understanding with them in all other 
matters. It is fortunate that recreation for the 
adult, which was formerly considered something 
to be indulged in quietly or even secretly, is now 
coming out in the open and taking its part in 
every well planned health program. 

145 



CHAPTER XIV 

THE PRE-SCHOOL CHILD 

The age from two to six is the most neglected 
period in the life of the child. Knowledge 
of infant feeding and hygiene has become so 
wide-spread that children in all circumstances 
of life now receive intelligent care during in- 
fancy. There is the trained nurse to advise 
and instruct the mother at the time of birth, and 
the specialist to be consulted either at the clinic 
or in private practice. This care represents 
the greatest advance of recent years in the 
science of medicine, and it is reflected in a 
steadily diminishing infant death rate. Even 
in so large a city as New York the work has 
been so thoroughly established that infant mor- 
tality is lower there than in the rest of the state. 
This same close attention to the health of the 
child is needed throughout the growing period. 

Following infancy, however, measured feed- 
ing is gradually discontinued, and there is a 
tendency to break away from the program so 
carefully planned for every hour of the day. 
By the time the child is two or three years old 

146 



THE PRE-SCHOOL CHILD 

he is usually allowed to choose his own food 
both as to kind and quantity, and his activities 
are regulated by his whim or the convenience 
of older members of the family. Faulty food 
and health habits are consequently formed, and 
there is too little attention to the matter of sleep. 
Physical defects are often neglected at this time 
in the belief that the child will outgrow them 
or that he is too young to be operated upon. 

Yet these are critical years in the matter of 
health, as a glance at the mortality statistics 
will show. Ninety per cent of the cases of 
measles and whooping cough occur under the 
age of five, as well as more than 95 per cent of 
the deaths caused by these diseases. Almost 
the same is true of diphtheria and scarlet fever. 
More than 50,000 children succumb to these dis- 
eases each year in America, and 70 per cent of 
this number die before they reach the age of 
five. One-fourth of all deaths occur before the 
end of the fifth year, or six times as many as 
in the next 10 years of life. 1 

Moreover, it is not merely the actual death 
rate of this period that is to be seriously con- 
sidered, but the complications and after-effects 
in those who survive the contagious diseases of 

1 Frederick S. Crum, "Medical Inspection of Schools— a 
Factor in Disease-Control." 

147 



NUTRITION AND GROWTH IN CHILDREN 

childhood. In the case histories of children 
treated for malnutrition, the source of this con- 
dition is traced over and over again to an attack 
of measles or whooping cough. Other diseases 
to which the pre-school child is subject are 
otitis, tonsillitis, bronchitis, and pneumonia. 
Since the malnourished child is especially sus- 
ceptible to infection, it is particularly impor- 
tant to guard against underweight during the 
years when the child is least immune to con- 
tagious children's diseases. These infections 
with their complications not only lower the re- 
sistance of the child, but retard his growth in 
both weight and height. 

Considering, then, the five chief causes of 
malnutrition as they affect the pre-school child, 
the prevalence of physical defects is nearly as 
great among children between two and six years 
old as in any other age group. This is a fact 
of great significance, as is also the high percent- 
age of naso-pharyngeal obstruction, which is 
the most frequent cause of malnutrition. Al- 
though, as has been stated, the tonsils do not 
usually become diseased before the age of five, 
adenoid tissue is more liable to cause obstruc- 
tion while the nasal cavities are small. This 
mechanical interference with breathing leads to 
congestion in the naso-pharynx, which is an- 

148 



THE PRESCHOOL CHILD 



Table IV. 



Average Number of Physical Defects at 
Various Ages 





Little Wanderers' Home 


Massachusetts 
General Hospital 


Age 


Per Cent 

of 

Total 

Group 


Average Number 
Defects 


Per Cent 

of 

Total 

Group 


Average 
Number Defects 




All 

Kinds 


Naso- 
pharyn- 
geal 


A1J 
Kinds 


Naso- 
pharyn- 
geal 


3 and under. 

4-6 

7-0 

10-12 

13 and over. 
Unknown . . . 
Entire group. 


12 

21 
23 
18 
17 
9 
100 


5.0 

5.0 
5.1 
6.0 
4.3 
3.5 
5.2 


3.9 
2.5 
2.3 
3.3 
2.4 
1.3 
2.5 


9 

23 

30 

28 

6 

4 

100 


6.0 

6.9 
7.2 
6.9 
6.0 
6.4 
6.8 


3.6 
3.5 
3.6 
3.8 
3.0 
3.5 
3.5 



other step towards infection. Many young chil- 
dren have almost constant naso-pharyngitis 
and frequent "colds." It is of the greatest im- 
portance that such obstruction be removed be- 
fore the sinuses are largely involved or before 
the child becomes infected with any of the con- 
tagious diseases. 

It is to be remembered that the position as 
well as the size and amount of adenoid tissue 
is of importance in causing obstruction; there- 
fore, the removal of a small adenoid may give 
as great relief as the excision of a larger mass 
of tissue situated on the lateral walls of the 
pharynx. 

Table IV gives the results of a study of de- 
fects according to age in two groups totaling 
602 children. 

149 



NUTRITION AND GROWTH IN CHILDREN 

Lack of home control, which is second among 
the causes of malnutrition with older children, 
is a less important factor in this group because 
the problem of control is simpler during this 
early period than with the child of school age. 
This is partly due to the natural dependence of 
the child on the mother, and to her relatively 
greater physical authority. It is also easier to 
continue or regain the firm control established 
during infancy than to begin anew after the boy 
or girl has been independent for a longer period. 

Overfatigue is, however, a more frequent 
cause of malnutrition with the younger child, 
and is a source of greater danger to growth and 
development than at a later period. This is the 
age when the child is especially imaginative, 
and when he reacts quickly to every new asso- 
ciation. The responsiveness of childhood is so 
attractive that it leads to over-stimulation on 
the part of older members of the family, who 
delight in exhibiting the child's growing ca- 
pacity. Visitors and even the chance passerby 
manifest an interest in his acts and sayings, to 
which he naturally responds with his best en- 
deavors. At no age is there greater risk of 
nervous overfatigue than during these early 
years of rapidly expanding observation and 
experience. 

150 



THE PRE-SCHOOL CHILD 

Children from the age of two to six are espe- 
cially prone to form faulty food and health 
habits, as previously stated, because of the lack 
of a fixed routine, and of the inadequate train- 
ing and supervision usually given at this period. 
Irregular eating is permitted, and the child is 
given sweets and other food at any hour of the 
day in order to please him or to keep him occu- 
pied. Some accidental experience at this time 
may lead to an aversion for certain necessary 
foods, which increases the susceptibility to 
rickets and other deficiency diseases. While 
the child is becoming accustomed to new foods 
it is of the utmost importance that milk and 
cereals should not be omitted from the diet. 
This is perhaps the most serious dietary dan- 
ger to which the pre-school child is subject. 

It is generally recognized that as little medi- 
cine as possible should be given during infancy, 
but there is an increased tendency to use laxa- 
tives and other drugs as a short-cut after the 
age of two, instead of taking the trouble to 
train the child in proper health habits. The 
convenience and pleasure of adults frequently 
lead to late hours for the child who is too young 
to be left at home alone, or who is afraid to go 
to bed without the companionship of an older 
person. Too often a tired child is allowed to 

151 



NUTRITION AND GROWTH IN CHILDREN 

fall asleep on a couch in the living room, or is 
carried out to an evening entertainment with- 
out any consideration of its possible injury to 
his health and growth. The excitement of Sun- 
days and holidays, which are often occasions 
also for over-indulgence in rich and sweet foods, 
is almost invariably reflected in the child's 
weight chart. 

The effect of these various errors in diet and 
hygiene may pass unnoticed for a considerable 
time because the regular weighing which has 
been part of the infant's routine is no longer 
considered necessary. The nutrition class 
therefore meets an urgent need of both the pre- 
school child and his mother, and this is the time 
when the nutrition program can be applied with 
the greatest immediate benefit and the most far- 
reaching effect. 

Although the class meetings may not always 
appeal to the child of this age to the same de- 
gree that they do to the older boy and girl, there 
is nevertheless sufficient interest in the weight 
chart and the stars to hold his attention. Since 
growth is relatively greater during the years 
from two to six, the actual gain in pounds is 
small, and therefore the chart can be made 
more graphic if the scale is doubled by allow- 
ing two squares for each pound of gain. 

152 



THE PRE-SCHOOL CHILD 

In the case of the mothers, the opportunity 
for getting results through their cooperation is 
greater than at any other period. The younger 
the child, the greater is the maternal solicitude 
for his welfare. It is not lack of interest, but 
lack of knowledge on the part of the mothers 
that has made these early years a period of neg- 
lect. They have had the aid of the milk station 
and the infant clinic in the past, and the nutri- 
tion class is welcomed as a further opportunity 
for health education. The weight chart is a 
link with the earlier experience of the parents 
in considering weight the standard of the 
child's condition. Even parents of foreign 
birth who have difficulty in acquiring the English 
language can follow the weight line on the chart 
with understanding, and know whether the child 
is making progress towards his normal stand- 
ard. 

The requirements as to mid-morning lunches 
and rest periods can be more easily carried out 
at this period, when the child has not yet become 
subject to school routine. This is a matter of 
considerable consequence in localities where 
nutrition work has not the hearty cooperation 
of the schools. In such cases the older child is 
hampered by a school program that not only 
produces overfatigue but interferes with its 

153 



NUTRITION AND GROWTH IN CHILDREN 

effective remedy by a strict adherence to the 
full schedule. 

No child should be admitted even to the kin- 
dergarten until every effort has been made to 
bring him up to normal weight. This can be 
accomplished best through the nutrition class 
for the pre-school child, and his weight chart is 
the best evidence as to when he is ready to take 
up the full school program. When the mal- 
nourished child is not given such care during 
the pre-school period, the added strain of school 
life makes it increasingly difficult to regain the 
ground lost, and he risks the danger of falling 
farther and farther below his normal standard 
of growth and health. The almost even per- 
centage of malnutrition found up through the 
various grades indicates that this retardation 
in growth tends to continue, and that such chil- 
dren remain stunted throughout their lives. 



CHAPTER XV 

THE OVERWEIGHT CHILD 

Overweight in children has not received the 
attention from either parents or physicians that 
its serious menace to health warrants. It has 
been the custom to think of it as a hereditary 
condition, or one that the child would naturally 
outgrow. Because of the lack of complaint 
from the victims themselves and also the fact 
that overweight is not accompanied by the con- 
spicuous physical defects that are characteris- 
tic of underweight, obesity has been viewed as 
a discomfort rather than a danger, and little 
has been done to standardize either diagnosis 
or treatment. 

What Constitutes Overweight? — The human 
being is a wonderful animal, equal to a great 
range of adjustment and adaptation. He seems 
to be capable of preserving a fair degree of 
health under conditions of great excess of fat 
and of remarkable leanness. It is difficult, 
therefore, to draw an exact line to separate 
these overweight children from the normal. 
Clinical evidence, however, corroborates the ex- 

155 



NUTRITION AND GROWTH IN CHILDREN 

perience of life-insurance companies that 20 
per cent above the averages now in use may be 
considered the limit o£ normal weight, and any 
excess should be investigated. In certain chil- 
dren there is a natural tendency to excess of 
fatty tissue, just as in others, to bony structure 
or to muscular development; but when the ex- 
cess passes beyond 20 per cent, we call the con- 
dition obese. 

Comparison of Overweight and Underweight 
Children with Respect to Physical Defects. — 
Practically every case of underweight has 
physical defects directly bearing on the condi- 
tion, and also nervous symptoms that are easily 
demonstrable. Overweight has no such appar- 
ent physical defects. Its symptoms are shown 
in the tax put upon the heart and other vital 
organs by the extra burden of weight carried. 
From this condition come lessened powers of 
endurance and diminished activity. In the 
matter of disposition, the fat child is usually 
good natured and amiable. 

As a result of the physical examination of a 
large number of children, we have found the 
underweight child averages nearly six defects, 
while the overweight child averages less than 
two. Cases are common in which it is impossi- 
ble to find a single physical defect in the over- 

156 



THE OVERWEIGHT CHILD 

weight child. Table V gives the results of one 
study of comparative defects. 



Table V. Comparison of Defects in 24 Overweight and 
24 Underweight Children 



Kind of Defect 


Number of Defects in 
Overweight Group 


Number of Defects in 
Underweight Group 


Obstructions to breathing 
Gingivitis 


21) 

5 
1 
1 





1 





2 

1 
1 
2 

1 
1 
1 
1 

47 


105 
1 


Carious teeth 


20 


Alveolar abscess 

Cerumen in ear 

Otitis media, chronic... 
Phlyctenular keratitis . . . 
Eczema 


1 
7 
2 
1 
1 


Albuminuria 


3 


Vaginitis, gonorrheal . . . 

Syphilis, hereditary 

Enuresis 




1 
1 


Lateral curvature 

Round shoulders 

Adherent prepuce 


2 
17 

2 
13 












Bronchitis 





Tuberculosis 












177 



In this study the overweight children ranged 
from 20 to 133 per cent above the average 
weight for their height, and the underweight 
group was made up of an equal number of un- 
selected children 10 per cent or more under- 
weight. It will be seen that the average number 
of defects for the overweight children was 
under 2, while the average for the underweights 
was 7.3. What is of even more signficance, 

157 



NUTRITION AND GROWTH IN CHILDREN 

only two of the first group had more than 3 
defects, while only three of the underweights 
had less than 6. Four of the obese children 
had no physical defects, and six had only one 
each, while twelve of the second group had 8 or 
more each. 

Danger of Overweight. — Although the over- 
weight children are especially free from defects 
that interfere with respiration, the extra bur- 
den put upon the lungs and circulation by their 
condition makes them less likely to recover 
from pneumonia, or other acute illness. In the 
case of infantile paralysis obesity is a handicap 
that often prevents recovery. Joslin states that 
overweight is a predisposition to diabetes. 
"The overweight is at least twice and at some 
ages forty times as liable to the disease." 1 

The body is constantly trying to eliminate the 
excess food taken. What cannot be eliminated 
is stored as fat. The effect of this condition is 
a tendency, in greater or less degree, to toxe- 
mia, which results in a disinclination to physi- 
cal or mental exertion, and hinders normal de- 
velopment. 

1 E. P. Joslin, "The Prevention of Diabetes Mellitus," 
Journal of the American Medical Association, Vol. 76, 
No. 2, January 8, 1921, pp. 79-84. 

158 



THE OVERWEIGHT CHILD 

In general it may be said that the younger 
the child, the less is the danger from over- 
weight. 

The Cause of Overweight. — The chief cause 
of obesity is the habitual intake of more food 
than is burned up. As a rule, this is the result 
of an appetite for foods of high caloric value, 
especially fats and sweets. The fat child, how- 
ever, may take less food daily than is eaten by 
a thinner child, and yet put on weight. This is 
explained only in part by the greater activity 
of the latter. A more important factor is that 
such defects as are found in fat children are 
usually those which do not interfere with nutri- 
tion. 

It is remarkable how general is the idea even 
among physicians that the usual cause of obe- 
sity is some abnormality of the endocrine 
glands. Such abnormalities do occur, but with 
the exception of those of the thyroid, are so 
rare that this cause may be disregarded except 
in large hospital clinics where such cases may 
be considered medical curiosities. The use of 
thyroid extract in the treatment of obesity is a 
short cut attended with danger to the growing 
tissues and is seldom, if ever, necessary. 

The Remedy for Overweight. — The remedy 
for overweight is measured feeding. The child 

159 



NUTRITION AND GROWTH IN CHILDREN 

should be weighed, and a careful record, in cal- 
ories, should be kept of his food for a week, 
with a second weighing to show how much fuel 
the body is able to consume in that period. A 
reduction of one-third of the daily average 
should then be made, which will afford an op- 
portunity for the burning up of some of the 
stored tissue. If the loss in weight each week 
does not exceed two pounds, the child will feel 
better while the reduction is going on, and will 
show a constant increase in efficiency. 

If there is no loss of weight with a reduction 
of one-third the amount of food usually taken, 
a further reduction of 100 calories per day 
should be made, until it is found what amount 
of food will bring about the desired rate of loss. 
The total amount may be reduced to 800 or 900 
calories per day, if necessary, without causing 
symptoms of starvation. 

The character of the food habitually taken 
should be changed so as to reduce or eliminate 
all foods of high caloric value, such as fat meats, 
butter, cream, candy, "made" dishes, pastry, 
and chocolate, and to substitute in their place 
lean meats, fruits, and vegetables, salads with 
little oil, bran muffins and bulky foods which 
will satisfy the appetite and prevent constipa- 
tion. 

160 




Figure 25 as overweight girt. 



Louise at twelve years was 100 pounds overwefght. Hor nbvsical 
growth examination failed to disclose a single defect, nor did an X-rav 
examination of the sella turcica, etc.. show any abnormalitv. Her over- 
weight condition was due to faulty food habits. The right half of the 
picture shows the result of restricting her diet to about SOO calories 
per day — a loss of 75 pounds in 3'2 weeks. An increase in height at 
the same time brought her into better proportions Her 
progress is shown graphically in Figure 20 



THE OVERWEIGHT CHILD 

Although successful treatment is essentially 
a matter of diet, physical exercise which is not 
overfatiguing will also assist the process of re- 
duction. Swimming, rowing, walking, and mod- 
erate exercise of any kind should be encouraged, 
but it is necessary to remember that many 
overweight children do not have sufficient 
strength for hard exertion, and have to train 
gradually for heavier tasks. 

Influence of Heredity. — While the natural 
tendency to excess of fatty tissue in certain 
children must be admitted, and this often ap- 
pears as a family characteristic, overweight is 
far more frequently caused by habit than by 
heredity. Many children are allowed to indulge 
themselves in overeating on the ground that 
they were born to be fat, and that nothing can 
save them from this condition. A similar con- 
dition in one of the child's parents may be the 
direct result of like habits uncorrected in youth. 
In our clinics we have had many cases of chil- 
dren believed to be destined to thinness by a 
resemblance to one or the other parent, who, 
when given special treatment and care, go be- 
yond normal weight and actually become obese. 
On the other hand, the fat children who have 
followed the directions here given show that 
there is no need of their continuing to suffer 

161 



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Figure 26. the case of louise 

This is the chart of Louise whose picture appears in Figure 25. It 
shows that while she was losing weight, she grew in height at 
nearly the average rate, illustrating that there is a physio- 
logical force that makes for the normal. 

162 







THE OVERWEIGHT CHILD 



from overweight. Every child should be con- 
sidered as an individual, and be given all possi- 
ble aid to a normal and healthy development. 

Figures 25 and 26 illustrate the results of 
a faithful reduction in food during a period of 
seven months. In spite of the marked loss in 
weight there was nearly the average increase in 
height, which operated to reduce the percentage 
of overweight in this case. Normal growth in 
height during the period of treatment tends to 
offset a certain amount of excess fat, and to 
bring the body into better proportions. 



CHAPTER XVI 

QUESTIONS COMMONLY ASKED 

We have had occasion to answer thousands 
of questions in our nutrition classes, in the con- 
sultation room, and in letters from parents. 
While these inquiries cover a wide range of top- 
ics, certain questions are sure to appear 
wherever a group of mothers begin to talk about 
malnourished children. From this experience 
the following representative questions have 
been selected, which it will be noticed center 
about the five principal causes of malnutrition, 
namely : physical defects, lack of home control, 
overfatigue, improper diet and faulty food hab- 
its, and faulty health habits. 

1. 75 underweight serious in a child who 
seems healthy, has a good appetite, and is as 
active as any child of his age? 

When the body weight is not sufficient to sus- 
tain the height, the muscles are apt to show 
lack of tone, and the nervous system is almost 
invariably unstable. An underweight child has 
less resistance to disease, and is less able to 
withstand nervous strain, as he lacks the re- 

164 



COMMON QUESTIONS 

serve provided by a normal body weight. If 
his food habits are corrected, his activity re- 
duced, severe physical exercise omitted, and 
rest periods taken morning and afternoon, it 
will soon be found that his weight has increased. 
His general condition will also show an improve- 
ment similar to that which appears after a long 
vacation, and you will realize that your stand- 
ards of health for the child have been inadequate. 

2. At what age is it safe to remove diseased 
adenoids and tonsils? 

In the case of adenoids we advise removal as 
early as they are found to be diseased or to 
cause obstruction. Under the age of five their 
removal is usually sufficient to relieve ob- 
structed breathing. The tonsils may be en- 
larged, but do not usually become infected ear- 
lier than the age of four or five. They should 
be watched, however, and if they become dis- 
eased, it is better to remove them at once. The 
child should be kept in bed five days to accom- 
plish full recovery and prevent loss in weight. 

3. Are enlarged cervical glands a sign of 
tuberculosis? 

Enlarged glands are an indication of various 
infections. The glands become enlarged in an 

165 



NUTRITION AND GROWTH IN CHILDREN 

effort to resist invading organisms. Enlarge- 
ment of the posterior cervical glands may be 
caused by organisms that come from the scalp 
dne to local irritation, but enlargement of the 
anterior cervical glands is usually secondary 
to diseased tonsils. The infecting organism 
may also be that of tuberculosis, and therefore 
the condition should receive prompt attention, 
especially in a debilitated child. 

4. Are carious teeth a serious cause of maU 



Small cavities in the teeth do not apparently 
affect nutrition, but alveolar abscesses and 
large cavities which affect approximation dis- 
turb the digestion and produce poison products 
which are absorbed. The teeth, therefore, 
should be given the best possible care, and even 
small cavities should receive prompt attention 
by a dentist. 

5. 7s tuberculosis in children always perma- 
nent? 

It is found that the majority of children under 
sixteen have had tubercular infection at one 
point or another, and although such infection 
is permanent, healing takes place about the 
tubercular process and it may cause no further 
trouble. The greatest safeguard against fur- 

166 



COMMON QUESTIONS 

ther extension is to keep the nutrition up to 
normal standards, and when this is done there 
is no reason why the child should not become 
strong and well. 

6. Is it proper to expose children to whoop- 
ing cough and other infectious diseases in the 
summer time in order that they may not take 
them at a more unfavorable season? 

Children should never be exposed to infec- 
tious diseases intentionally. Whooping cough, 
measles, and scarlet fever often have serious 
after effects, and the younger the child the 
greater the danger. Where these diseases can- 
not be avoided, the patients should be given 
special care to prevent loss in weight and con- 
sequent malnutrition. 

7. What do you mean by a "defect"? 

A defect is an abnormal organic physical con- 
dition. Most defects fall into two large classes ; 
those due, first, to inflammatory processes 
which cause malnutrition, such as diseased 
adenoids or tonsils, carious teeth, otitis, pye- 
litis, and the inflammatory conditions caused by 
pediculosis and worms; and, second, those de- 
formities that are a result of malnutrition, such 
as fatigue posture, round shoulders, lateral 
curvature and flat feet. We also include as de- 

167 



NUTRITION AND GROWTH IN CHILDREN 

f ects such nervous disturbances as enuresis and 
chorea. 

8. Should a child be made to lie down when 
he cannot sleep? 

The child who does not fall asleep naturally- 
after several hours of activity is probably suf- 
fering from nervous over-stimulation as a re- 
sult of fatigue. This is an indication that he 
has special need of rest. There may be cause 
of his failure to sleep in the conditions of the 
room as to light, heat, or noise. Frequently the 
wakefulness is due to the mistaken notion that 
he will go to sleep more quickly if he is allowed 
to take toys and books to bed with him. He 
should be taught to lie quietly for a short period 
and then gradually lengthen the time. Eest 
does not necessarily mean sleep, but when a 
child has once learned to rest quietly he usually 
drops off to sleep. It is valuable training to 
acquire in early life the habit of being able to 
turn the tide of fatigue during the day by a few 
minutes of thorough rest. 

9. Does a child get really "good sleep" in 
the daytime? How much sleep is necessary? 

The number of hours a child may sleep to ad- 
vantage varies within what may be called a zone 

168 



COMMON QUESTIONS 

of safety. Long hours of sleep will not neces- 
sarily prevent overfatigue. A child may sleep 
14 hours a day, and yet suffer from too great 
or too continuous mental or physical activity 
during the other 10 hours. Overfatigue is best 
prevented by the use of rest periods during the 
day, which provide a new supply of energy 
before the child has gone beyond the limit of 
his strength. 

People living in tropical climates have 
learned to divide their sleeping time by taking 
a siesta in the middle of the day, thus increas- 
ing the amount of time for other purposes in 
the freshness of the morning and the cool of 
the evening. 

Because so many hours are spent in sleep it 
is important that the air in the room should 
be as fresh as that outdoors. 

The child of school age should have from 10 
to 12 hours of sleep at a regular time, aside from 
his rest periods. 

10. What does it mean when a child grinds 
his teeth in sleep? 

This may be a sign of worms, adenoid or 
tonsil infection, indigestion, overfatigue, or 
nervous disturbance. Whenever it is noticed, 
the cause should be sought and removed. A 

169 



NUTRITION AND GROWTH IN CHILDREN 

careful following of the nutrition program will 
meet the need in the case of any of these causes 
except worms, for which special treatment is 
necessary. 

11. What is the best treatment for 
"worms"? 

In case intestinal parasites are suspected, a 
physician should be consulted, as it is easy to 
mistake shreds of cellulose in the stools for 
thread worms. When worms are found, treat- 
ment should be carried out under a physician's 
directions. Do not trust "worm cures' ' or 
other patent medicines. Injury is frequently 
caused by repeated injections and purges. 
Treatment should continue until all traces of 
either worms or eggs have failed to appear for 
at least two weeks. When treatment is stopped 
before this is accomplished, conditions are soon 
as bad as ever. 



12. Why do certain foods disagree with one 
child and not with another? 

This may be due to a food idiosyncrasy which 
in most cases is gradually outgrown. The 
symptoms may be convulsions, a rash resem- 
bling eczema, or throat difficulty similar to bron- 
chitis and asthma. The foods most apt to dis- 

170 



COMMON QUESTIONS 

agree with children are egg albumen, cow's milk 
(rarely), oatmeal, nuts, strawberries, raw ap- 
ples, and shell fish. Proteid tests by a physi- 
cian will determine the kinds of food which it 
is necessary to limit in a given case. 

Children have varying ability to digest cer- 
tain kinds of food. For example, butter fat 
may be perfectly digested, but cream will cause 
indigestion. Such variations are within normal 
limits, but care should be exercised in forcing 
a child to take too much of any food for which 
he has an aversion. 

13. Why are tea and coffee injurious? What 
is the effect of cocoa? 

Drugs have a very serious effect upon grow- 
ing tissue. There appears to be a lack in child- 
hood of the immunity that usually develops 
with maturity. Tea and coffee contain about 
two grains of caffein to the cup or glass. Even 
weak tea or coffee gives to a child nearly as 
much of the drug as would be contained in an 
ordinary dose. 

The theo-bromine in weak cocoa does not 
show any bad effect, and a small amount of 
cocoa gives a flavor to milk and thus renders it 
palatable to many children who would otherwise 
have difficulty in taking as much milk as they 

171 



NUTRITION AND GROWTH IN CHILDREN 

need. When cocoa is given for mid-morning and 
mid-afternoon lunches, it should be only slightly 
sweetened, as the sugar diminishes the appetite 
for the next meaL The most important differ- 
ence between cocoa and the other drinks is that 
there does not seem to be any desire to increase 
its strength, and children do not form a "cocoa 
habit." 

14. How can constipation be cured without 
drugs? 

The child should be trained to a regular move- 
ment of the bowels at the same time every day, 
preferably just after breakfast. A suppository 
or an injection of an ounce of liquid petroleum 
may be used to start the habit. One or two 
glasses of water taken before breakfast are 
helpful, and coarse cereals, vegetables, and 
fruit will also act as laxatives. Bran stirred 
into the cereal is beneficial, or cooked bran 
eaten with cream and sugar. Oatmeal and 
cornmeal bread sweetened with molasses are 
good foods. Prunes and figs are also useful. 
Concentrated foods such as rich cakes and 
pastry should be carefully avoided. 

Constipation is usually a symptom of indiges- 
tion; therefore, plenty of time at meals and 
good food habits are important. Until regular 

172 



COMMON QUESTIONS 

bowel habits are established liquid paraffin may 
be used, as it is not a drug and does not form a 
habit. It should be given to the child in doses 
of two to four teaspoonfuls before meals or on 
retiring. 

These measures should be sufficient, but if 
constipation persists other causes must be 
looked for, such as intestinal obstruction, adhe- 
sions, or sub-acute appendicitis. 

15. How can enuresis be cured? 

Enuresis, or bed-wetting, is not a disease but 
rather the persistence of an infantile condition 
or habit. Most children gain control of the blad- 
der by the end of the third year when properly 
trained. The "wet habit' ' is a serious matter 
in any family, but when it is found among chil- 
dren for whom foster homes are being sought, it 
seriously affects their opportunities for adop- 
tion or for placing in desirable families. 

Most cases can be cured within a week by the 
following treatment : 

No liquids or fruit to be taken after 4 p.m. 

A rather light dry supper; for example, a cereal 
with not more than a tablespoonful of milk. 

A bland diet; no tea, coffee, or highly seasoned 
foods at any time, and no candy or desserts between 
meals. 

173 



NUTRITION AND GROWTH IN CHILDREN 

The bladder emptied on going to bed and at inter- 
vals of one hour until midnight, and of two hours 
from then until morning. These periods should be 
lengthened one-half hour each night. An alarm clock 
is useful at night, and a chamber should be placed on 
a rug at the bedside convenient for use. 

When it is found that a child wets himself at 
a certain hour, the bladder should be emptied 
half an hour before that time for several days 
until the habit is cured. This is especially apt 
to occur about one hour after going to bed. 

The child should be encouraged by stars and 
other rewards for every dry day and dry night. 
He should not be punished for bed-wetting, as 
it is involuntary and he does not know when the 
act occurs. Encourage him to be alert to feel 
the need of emptying his bladder. Guard 
against overfatigue and excitement. Be insist- 
ent upon the mid-morning and mid-afternoon 
rest periods. Drugs are of little or no use. 
Patience and persistence will win out in prac- 
tically every case. 

16. If a malnourished child is brought up to 
standard, does he stay up to standard? 

In order to bring a child up to normal weight 
it is necessary to find the cause of his poor 
nutrition, to remove the cause, and to teach him 

174 






COMMON QUESTIONS 

good food and health habits. Therefore, after 
he gets well the knowledge and habits thus ac- 
quired serve to keep him so. Relapses do occur 
due to causes over which neither children nor 
parents have control; but otherwise the mal- 
nourished boy or girl's chances of keeping well 
are equal and possibly better than those of a 
child who has never been malnourished. 

17. Is it safe to omit milk from the diet of a 
growing child? 

No. Milk is the only complete food for hu- 
man beings, and is the greatest safeguard 
against any deficiency in either the character 
or amount of the diet. The well child should 
have a pint of milk every day, and the under- 
nourished child should take a quart in one form 
or another. At least a pint of milk should be 
taken daily all through the growing period, that 
is, until maturity. Some of the most pro- 
nounced and serious cases of malnutrition are 
found among those children who have omitted 
milk from their diet. 

18. What are vitamins, and in ivhat foods 
do they occur? 

The term " vitamins'' is used to designate 
certain accessory food products necessary for 

175 



NUTRITION AND GROWTH IN CHILDREN 

normal growth. These accessory factors are of 
three kinds. 

"Fat-soluble A" is known as the antirachitic 
factor, and occurs mainly in: (a) certain fats 
of animal origin, and (b) in green leaves. The 
most notable deposits are in cream, butter, beef 
fat, cod liver oil, and egg yolk. The leafy vege- 
tables that contain it are chiefly celery, lettuce, 
onions, cauliflower, cabbage, Brussels sprouts, 
spinach, Swiss chard, and beet tops. 

"Water-soluble B," known as the anti- 
neuritic (beri-beri) factor, is found in almost 
all natural food products, its principal source 
being the seeds of plants and eggs of animals. 
Yeast cells are a rich source, also the germ and 
outside layer (the bran) of cereals, but it is 
absent in polished rice and white wheat flour. 

The antiscorbutic factor occurs in fresh vege- 
tables, and largely in lemons, oranges, raspber- 
ries, and tomatoes. Potatoes, milk, and meat 
possess a definite but low antiscorbutic value. 

The following table, taken from that prepared 
by the British committee appointed by the 
Medical Eesearch Committee and the Lister In- 
stitute for use during the war in famine-stricken 
districts, shows the distribution of these acces- 
sory factors in the commoner foods. 



176 



COMMON QUESTIONS 



Table VI. 



Distribution of the Three Accessory Factors 
in the Commoner Foodstuffs * 



Classes of Foodstuff 


Fat- 
Soluble A 
or 
Antirachitic 
Factor 


Water- 

Soluble B 

or 

Antineuritic 

Factor 


Antiscorbutic 
Factor 


Fats and oils: 
Butter 


+ + + 

+ + + 
+ + 

See note t 


+ 

+ + 
+ + 
+ + 



+ + 

? 

+ + 

less than+ -f 

undetermined 

+ 

+ 

+ + 
+ + 






+ 

+ + 
+ 
+ 

very slight 
if any 

very slight 
if any 
+ + 

very slight 

+ 

+ 
+ 

+ 

+ 

+ + + 
+ + + 




Cream 




Cod-liver oil 

Beef fat or suet 

Peanut butter and nut 
butter 




Margarine from beef fat 
Margarine from vege- 
table fats or lard. . . 

Meat, fish, etc.: 

Lean meat (beef, mut- 
ton, etc.) 


+ 


Liver 


+ 


Kidneys 




Heart 




Fish, white (cod, had- 
dock, etc.) 

Fish, fat (salmon, her- 
ring etc.) 




Fish, roe 




Tinned meats 

Milk, cheese, etc.: 

Milk, cows', whole, raw 
Milk, cows', skim, raw 
Milk, cows', whole, dried 
Milk, cows', whole, 
boiled 




+ 
+ 
less than -f- 

less than + 


Milk, condensed, sweet- 
ened 




Cheese, whole milk . . . 
Cheese, skim milk .... 

Eggs: 

Fresh 


?0 


Dried 


?0 







* Hess considers this list too restricted, and emphasizes the 
value of potatoes, and also of canned tomatoes, which his experi- 
ments show are rich in the antiscorbutic factor. Preserving does 
not necessarily injure the vitamins provided the foods are fresh 
when canned. Powdered or canned milk may prove of great value 
where a good supply of fresh milk cannot be obtained. 

t Value in proportion to amount of animal fat contained. 

177 



NUTRITION AND GROWTH IN CHILDREN 



Table VI. Distribution of the Three Accessory Factors 
in the Commoner Foodstuffs*— Continued 



Classes of Foodstuff 



Cereals, pulses, etc.: 

Wheat, maize, rice 
whole 

Wheat, maize, germ . . 

Wheat, maize, bran . . . 

White wheaten flour, 
pure cornflower, pol 
ished rice, etc 

Dried peas, lentils, etc. 

Vegetables and fruits: 
Cabbage, fresh, raw 
Cabbage, fresh, cooked 

Lettuce 

Spinach 

Carrots, fresh, raw... 

Carrots, dried 

Potatoes, cooked 

Tomatoes, canned .... 
Lemon juice, fresh . . . 
Lemon juice, preserved 
Orange juice, fresh . 

Apples 

Bananas 

Nuts 



Miscellaneous : 

Yeast, dried 

Yeast, extract and 
Yeast, autolyzed . , 



Fat- 
Soluble A 

or 

Antirachitic 

Factor 



+ 

+ t 



+ + 



+ + 
+ + 

very slight 



Water- 
Soluble B 
or 
Antineuritic 
Factor 



+ + + 
+ + 





+ + 



+ 
+ + 



+ + + 
+ + + 



Antiscorbutic 
Factor 



+ + + 

+ 
+ + 

+ 



+ + 
+ + + 

very slight 



A glance at this table will show that the wide 
distribution of these elements clearly indicates 
their liberal nse in the average American diet. 
McCollum says : * "It is now well demonstrated 
that with the diets employed in Europe and 
America there is no such thing as a 'vitamin' 



1 E. V. McCollum, "The Newer Knowledge of Nutrition," 
p. 138. 

178 



COMMON QUESTIONS 

problem other than that of securing an adequate 
amount of the substance, Fat-soluble A." He 
accordingly recommends milk and the leafy- 
vegetables as "protective foods,' ' including 
eggs in the same class. 

In our nutrition classes at least a pint of milk 
a day is prescribed for every child, and when 
the diet lists have been checked and corrected 
according to the methods described, I have 
never known a case of malnutrition that could 
properly be diagnosed as "lack of vitamins." 



PART III 

A NUTRITION PROGRAM 
FOR THE COMMUNITY 



CHAPTER XVII 

THE NUTRITION CLASS 

Although many features of our nutrition 
program can be applied with excellent results 
in the care of the individual child, a well organ- 
ized nutrition class is the most effective agency 
in the treatment of malnutrition. This is true 
in the case of the rich and the well-to-do as well 
as among the poor, for children are alike in their 
response to the stimulus of the class and the 
spirit of competition. 

The class method is based on the principles 
of group association and visual instruction. 
Children are quick to imitate, and to learn 
from one another. They recognize and respect 
"good form" in any group to which they may 
belong, and the business of getting well assumes 
a new importance in their minds when they see 
it as the aim and purpose of their associates. 
The rising line of the weight chart and the im- 
proved appearance of those who gain teach a 
lesson that is clear to all. 

The child's own interest is so aroused by the 
chart's record of his progress that on several 

183 



NUTRITION AND GROWTH IN CHILDREN 

occasions I have known children to burst into 
tears when they failed to gain. Often, when the 
weather is so severe that scarcely a patient ap- 
pears in the other divisions of the hospital, the 
nutrition class registers full attendance. 

Class Organization. — The simple procedure 
of weighing and measuring forms the basis of 
selection. Classes of not more than 20 children 
each are formed from those whose weight is 
seven or more per cent below the average. Each 
child is then given thorough physical, mental, 
and social examinations, as previously de- 
scribed, and receives such advice and instruc- 
tion as his condition requires. The object of 
the class is to check up the results of the in- 
structions given, and to make further recom- 
mendations as they may be needed. 

A weight chart is made out for each child, 
w T ith his name, age, height, and weight at the 
top, and a line showing the average weight for 
his height. Since a normal increase in both 
weight and height is to be expected throughout 
the growing period, this average weight line 
does not represent a fixed number of pounds, 
but is a curve allowing for an expected increase 
of from three to thirteen pounds per year, ac- 
cording to the age of the child. His actual 
weight line is made by connecting the dots rep- 

184 




Figure 27 the case of Dorothea, before treatment 



Dorothea, aged eleven, became tired on slight exertion, so tired that It 
took her nearly an hour to dress in the morning. She would sit and 
dream, rarely smiled, and her face looked distressed. She passed the 
school medical inspection, but was {riven a tonic by her family 
physician. The hospital diagnosis was "No disease." The nutrition 
diagnosis was: underweight 21 per cent: naso-pharyngeal obstruction: 
cervical adenitis: carious teeth: spinal curvature: fatigue posture. 
Nutrition treatment was begun with the result 
shown in Figure 28. 



THE NUTRITION CLASS 

resenting his first weight and the subsequent 
weekly weighings. 



m 



!!;[! 



££<§££ 



Q*M>v lr 



kzzlmiiii^tii 



as"!: 









%. 



fcJ5 



71, 



i |iii 



; 



m 



u* 



U 



m 



Figure 28 the case of Dorothea 

After the second weighing her mother was in the hospital for 11 
weeks, but Dorothea continued by herself to follow all directions, 
gaining at the rate of half a pound a week. This was increased 
to over a pound a week when she returned to the class, but reduced 
to half a pound again at a summer camp which did not supply 
mid-morning and afternoon lunches. Her total gain 
was 24% pounds in 36 weeks. 

When the actual weight line reaches the aver- 
age weight line a new average weight must be 

185 



NUTRITION AND GROWTH IN CHILDREN 

computed on the basis of the actual height of 
the child at this time, in order to allow for the 
probable growth in height while he has been in 
the class. It is only when the child attains this 
new weight that he is considered ready for 
"graduation." 

A quiet room large enough to accommodate 
about fifty persons should be provided for the 
nutrition class, where it will be free from inter- 
ruption. The class meets once a week at a 
regular hour, and the children come to the class- 
room accompanied by their parents. No child 
should be admitted regularly to the class except 
at the request of his parents, because their co- 
operation and interest are essential factors in 
successful treatment. 

Class Procedure. — As the children arrive they 
are weighed by the nutrition worker, and their 
weight recorded on the charts. Each child 
brings a 48-hour diet list, which is checked up 
by the nutrition worker or her assistants, not 
only with reference to its total food value, but 
also for the kinds of food taken, and especially 
to note whether it contains in sufficient amount 
milk, cereal, and other essential foods. The 
average number of calories is recorded on the 
weight chart, where it often affords significant 
comparison with the rise or fall of the weight 

186 




Figure 29. the case of Dorothea, after treatment 



Notice the transformation In both mental and physical condition fol- 
lowing the increase in weight shown in Figure 28. Dorothea's mother 
says, "Her whole disposition has changed, she laughs, and is cheerful 
and happy." She overcame her finicky likes and dislikes and faithfully 
carried out the directions given because she was anxious 
to become well and strong. 



THE NUTRITION CLASS 

line. The nutrition worker also questions the 
child in regard to his activities during the pre- 
ceding week, and seeks to find the cause in case 
of failure to gain. Notes of her findings are 
added to the child's record for the doctor's in- 
formation. 

A blue star is affixed to the weight chart to 
indicate that rest periods have been faithfully- 
taken during the week, and a red star provides 
a similar record in regard to lunches. A green 
star may be used to record the attendance of 
one or both parents. This encourages regular 
attendance on the part of the parents, and may- 
be of interest in showing that the best gains are 
made by those children whose parents are inter- 
ested enough to come to the class regularly. 

The charts are then hung on the wall in the 
order of the gains made, and the children are 
seated in the same order with their parents be- 
hind them, all facing the charts. A gold star 
is added to the chart of the child who has gained 
the most during the week and is sitting in the 
place of honor at the head of the class. 

These preliminaries are completed before the 
stated time for the doctor's arrival, and he is 
thus enabled to see at a glance the results ac- 
complished during the week. Much of the in- 
struction needed can be given in general advice 

187 



NUTRITION AND GROWTH IN CHILDREN 

to the whole group, and individual recommenda- 
tions based on the record of the charts will be 
useful to all. Many a mother comes to see more 
quickly what should be done for her own child 
when its effects are pointed out in the case of 
another boy or girl. 

There is great teaching value in comparing 
the child at the head of the class with one who 
has not gained, and explaining the reason for 
the results in each case. The force of public 
opinion in the class group can in this way be 
made a powerful ally in removing such simple 
causes of failure as the neglect of rest periods 
or lunches, prejudice against open windows, 
and overfatigue arising from late hours or un- 
necessary tasks. Care must be taken, however, 
not to discuss openly matters about which either 
parent or child is rightly sensitive. 

Food and Rest. — During the period of treat- 
ment in the nutrition class the child should be 
placed in an open-air, or at least an open-win- 
dow, class, and school pressure should be re- 
duced. Most children need only sufficient addi- 
tional time for a lunch and rest period at 10 : 30 ; 
others will work to best advantage on a half- 
day schedule; a few need to be limited to two 
hours a day; while in certain cases the child 
cannot safely attend school at all for a time. 

188 







CO* 

c - 



r - ■'■ 












I If! 

t- o c 

tL X O — 

» c ° " 



K , 






THE NUTRITION CLASS 

One rest period of at least half an hour 
should be taken before the midday meal, and 
in the middle of the afternoon a longer rest, in 
order to save the child from overfatigue. The 
rest periods should be taken as described in 
Chapter IX. 

Mid-morning and mid-afternoon lunches are 
recommended for all undernourished children. 

In addition to the general advice given to all, 
both the physician and the nutrition worker en- 
deavor to discover every obstacle to each child's 
progress, and recommend such changes as the 
needs of the individual require. The nutrition 
worker visits the home to assist the parents in 
planning for the essentials of health, and to see 
that recommendations have been understood 
and carried out. 

The special work of the physician and of the 
nutrition worker in connection with, the class is 
discussed in the chapters following. 

Results Secured. — Successful treatment in 
the majority of cases is both easy and sure, pro- 
vided either the physician, the nutrition worker, 
or the teacher has the ability to create the 
vision of health in the child's imagination, and 
thus secure his complete cooperation. Where 
there is, in addition, the hearty cooperation of 
the home and the school, the child should reach 

189 



NUTRITION AND GROWTH IN CHILDREN 

his normal standard of weight in 10 or 12 weeks. 
It is recognized that the nutrition program 
demands from the child a self-denial and stead- 
fastness of purpose to which he has not been 



NUTRITION CLASS 



T 



HIS IS TO CERTIFY THAT 

GV-\av\e,s CUqsc, 




HAS ATTAINED THE REQUIRED 
STANDARD OF HEALTH AND 
WEIGHT OF(P ^ Vu,v ^r K .^POUNDS 

SIGNED ^^y? } ( ^< & MsL<t*7& 7*7- -3 
DATE lanuQXu l\^\HJLQ 



FlGUBE 31. NUTRITION CLASS DIPLOMA 

This certificate is given when the child reaches the average weight 

for his height. It is highly prized by the "graduates" as a 

recognition of their own efforts to get well. 

accustomed. For this reason the matter of 
" graduation' } from the class is made something 
of a ceremony, and he is made to feel that the 
certificate given is a well-earned diploma. 

In the early stages of this work we considered 
we were getting good results when we were able 

190 






THE NUTRITION CLASS 



to double the average rate of gain as shown by 
the tables. We now expect an average increase 
of 300 to 400 per cent, and have class records 
showing a group gain of 1,400 per cent of the 
expected rate of increase. These results, con- 
trasting with the published reports l of gains 
made in diet classes, school-lunch campaigns, 
and other partial efforts to combat malnutri- 
tion, justify the comprehensive program of our 
nutrition classes, and emphasize the importance 
of the medical foundation of the work. 

Summary. — The class method in the treat- 
ment of malnutrition has many advantages, 
which may be summarized as follows : It 

Economizes the time of all concerned by bringing the 
parents to the class, and thus minimizing the 
necessity for home visits ; 

Secures the cooperation of the parents — a vital factor 
in making results permanent; 

1 There was a gain of 170 per cent in an experiment con- 
ducted by Teachers College, Columbia University. (Mary 
S. Rose and Gertrude G. Mudge, "A Nutrition Class in Co- 
operation with a Summer Play School," Journal of Home 
Economics, February, 1920, Vol. 12, No. 2.) 

The gain was 125 per cent in an experiment conducted 
by the Hampden County Improvement League, Chicopee 
Falls, Massachusetts. (Minnie Price, "School Lunches and 
Educational Work to Overcome Undernourishment." 
Massachusetts Department of Health, The Common- 
health, July-August, 1920, Vol. 7, No. 4, pp. 262-267.) 

191 



NUTRITION AND GROWTH IN CHILDREN 

Pools the experience of all families for the benefit of 
each ; 

Favors study and correction of home difficulties by- 
contact with parents under friendly circum- 
stances ; 

Introduces a healthy form of competition ; 

Utilizes the approval of companions to influence the 
child to follow directions; 

Visualizes the essentials of health — an effective 
method in health education ; 

Removes prejudices and fears through knowledge of 
results obtained, and convinces in a moment when 
hours spent in argument have failed ; 

Overcomes obstacles too great for the authority of 
the parent and for the undeveloped reason of 
the child, which yield in a surprising manner 
to the interest developed in the class ; 

Provides a program whereby children can be made 
well in their own homes without adding to the 
family budget ; 

FurnisJies a basis for cooperation on the part of edu- 
cational, medical, and all child-helping organiza- 
tions in a practical community health program. 



CHAPTER XVIII 



THE NUTRITION WORKER 



The successful nutrition worker must have 
the following qualifications : 

1. Executive ability for organization and adminis- 
tration 

2. Genuine interest in children and ability to 
teach 

3. Practical experience in a children's medical 
clinic 

4. Training in the principles of nutrition work, in 
chart-making, and the keeping of records 

5. Practical experience in conducting nutrition 
classes 

It is her chief duty to see that each child who 
comes under her care has the essentials of 
health. In order to accomplish this she must 
coordinate the efforts of the parents, the phy- 
sician, the teacher, and the child himself. 

Her first contact with the parents comes at 
the time of the weighing and measuring, and 
she should use this opportunity to help them 
understand the significance of underweight. At 
the first class meeting she has a further oppor- 

193 



NUTRITION AND GROWTH IN CHILDREN 

tunity to interest thein in their child's condition 
by means of the weight chart and by explaining 
the need of the physical-growth examination. 

When the class is definitely organized, she is 
no longer dealing merely with a single family 
unit, but has the larger social problem of cre- 
ating a class spirit with its alternating influ- 
ences of mutual aid and competition. She must 
interest the physician in the class as a group, 
and help him become identified with its varied 
problems. 

Adjustment of the daily programs should be 
made at once and steps taken for the removal of 
defects that all children may become "free to 
gain" as soon as possible. 

Everything should be planned to lead directly 
to the chief object in view — bringing the chil- 
dren up to the normal weight line. In the ar- 
rangement and equipment of the classroom con- 
sideration must be given not only to the needs 
of the children and the convenience of the phy- 
sician, but also to the problems of the school 
or hospital in which the class is conducted. 
Foresight in planning the details of the work 
will save time for the physician, the parents, 
and all concerned. 

The nutrition worker arranges to have the 
physical-growth examination made as promptly 

194 



TUE NUTRITION WORKER 

as possible. She takes the dictation of the ex- 
amining physician that she may know exactly 
what defects are found. The parents should 
be made to see that she understands every re- 
mark made by the physician so that later she 
will be able to interpret authoritatively any- 
thing that may not be clear to them. In these 
and many other ways she must seek to gain their 
interest and confidence. 

In the removal of physical defects brought 
out by the examination many difficulties are en- 
countered. School, home, and clinic schedules 
must be brought into harmony that the recom- 
mendations of the physician may be carried 
out without delay. Tbe worker's records must 
show clearly what has been accomplished so 
that the physician will have an intelligent un- 
derstanding of each case at the weekly meeting 
of the class. 

The Nutrition Worker and the Physician. — 
The class should meet at least half an hour in 
advance of the arrival of the physician. The 
nutrition worker assumes all responsibility for 
making and keeping the weight charts, check- 
ing the diet lists, and attending to the class 
records. It is only by adequate preparation on 
her part that the physician is able to conduct 
the class in the short space of half an hour. 

195 



NUTRITION AND GROWTH IN CHILDREN 

Upon the thoroughness and accuracy of the in- 
formation that she supplies will largely depend 
the instructions that he gives for the ensuing 
week's program. 

No part of her work calls for more judgment 
and tact than her relations with the physician. 
Not only must she assist in carrying out his 
recommendations, but when this has been done 
and the child still fails to gain, she must put 
him on his mettle to look deeper into the cause. 
Instead of being satisfied with the 75 or 80 per 
cent of the class who are making the desired 
progress, she must direct special attention to 
every child who fails to gain, so that the phy- 
sician will feel the challenge and devote special 
attention to these problems. 

Individuals will be found who require a long 
period of observation and study by both nutri- 
tion worker and physician before a definite 
diagnosis can be made. In one of our classes 
a boy was under observation for a year and a 
half before his trouble, cardiospasm, was dis- 
covered. The cause must be found in every 
instance before recovery can be expected. 

Visitors. — Although visitors should be wel- 
comed, they should not be allowed to interrupt 
the class exercise. The best service that can be 
rendered to a serious inquirer is a convincing 

196 



THE NUTRITION WORKER 

demonstration of what can be accomplished in 
a class period. The nutrition worker should 
not allow herself to be diverted by "the gal- 
lery," but may explain the work in detail to 
those who are willing to remain after the class 
is dismissed. 

A Social Diagnostician. — The nutrition worker 
is so closely concerned in the social examina- 
tion that she may be called a social diagnos- 
tician. With the exception of physical defects, 
the chief causes of malnutrition have their roots 
in the social conditions that surround the child. 
It is the business of the nutrition worker first 
to discover, and then by her teaching to en- 
deavor to remove, lack of home control, over- 
fatigue, and faulty food and health habits. She 
must become the focus of all the social forces 
affecting the welfare of the child, conferring 
with parent, teacher, clergyman, or other person 
in authority in any particular case. She is the 
intermediary between the physician and the 
parents, and must represent his authority both 
in class conferences and home visits. 

Previous training and experience in a special 
field may make it difficult for the nutrition 
worker to see the whole problem without preju- 
dice in favor of the single factor with which she 
is most familiar. This tendency is most com- 

197 



NUTRITION AND GROWTH IN CHILDREN 

mon with reference to diet. After repeated 
demonstrations to the contrary, many workers 
still fail to realize that while improper diet is 
a significant item, it is not the first or chief 
cause of malnutrition, but actually fourth in the 
list, and shares even this place with faulty food 
habits. 

Home Visits. — When the nutrition class is 
properly organized, the necessity for home visit- 
ing is reduced to a minimum. We have found 
one nutrition worker able to care for more chil- 
dren by the class method than would usually be 
assigned to three or four social workers where 
home visiting is the chief feature of the pro- 
gram. This is accomplished by group teaching 
when the class is in session, and by individual 
conferences with the mothers before and after 
the class. When instruction is made graphic 
by the weight chart and results are apparent 
in the case of other children, the mothers be- 
come thoroughly convinced. Nevertheless, a 
certain amount of home visiting is not only 
necessary but desirable. 

The nutrition worker should go into the home 
in the same spirit in which the doctor makes his 
visit. It is recognized that the physician's call 
is for the definite purpose of removing illness 
and getting the patient well. He allows nothing 

198 



THE NUTRITION WORKER 

to divert him from this purpose, and never be- 
trays the family's confidence. The nutrition 
worker must observe the same scrupulous re- 
gard for the dignity of the family and her own 
professional standing. 

Where she has won the full confidence of the 
parents in the class conferences, she can usu- 
ally make her visit to the home the result of a 
direct invitation. Her inquiries here should be 
confined to the definite business which brought 
her to the home, and center about the essentials 
of health for the particular child under her care. 
Hygienic policing is no part of her work. She 
may incidentally observe a case of infectious 
disease that calls for control by the Department 
of Health, or a matter that requires the atten- 
tion of the Society for the Prevention of Cruelty 
to Children; but she must stick to her job, and 
refer these cases to the organizations that have 
been established to meet such needs. 

As nutrition work develops, the need for 
visits to the homes of the rich is increasingly 
recognized. One of the chief objects of the 
home visit is to observe the child's sleeping ar- 
rangements, and this need is sometimes as great 
in the homes of the wealthy as among the poor. 
For example, two growing girls in a family of 
wealth were found to be sleeping in a room 

199 



NUTRITION AND GROWTH IN CHILDREN 

lined with heavy draperies, with their beds close 
against the wall in corners filled with dead air. 
Their father was so afraid of drafts that he 
was in the habit of getting up in the night to 
close all windows that chanced to be open. 

One of the daughters later went around the 
world to search for the health that could have 
been found at home by remedying the condi- 
tions just described. Her sister has had severe 
attacks of pleurisy, and is probably tuberculous, 
but, although she is now a trained social 
worker, she is not able to get away from the 
habits and prejudices of her childhood, and still 
sleeps with her windows tightly closed. 

An occasional visit to the home at night will 
often lead to a better understanding of the 
child's case. Frequently, children will be 
found to sleep facing the light, with beds 
against the wall in a dead air space and only 
one window open, which, moreover, may be 
away from the prevailing wind. Even that sin- 
gle window is often kept closed until the par- 
ents retire, which may be several hours after 
the children have gone to bed. Growing chil- 
dren need fresh air every hour of the twenty- 
four. 

In dealing with those in less favorable cir- 
cumstances it must be borne in mind that the 

200 



THE NUTRITION WORKER 

more ignorant a person is, the easier it is to 
hurt his feelings. It is a good rule to meet all 
parents in such a way as to bring out their best 
qualities, and to see as much good and as little 
bad in the situation as possible. The nutrition 
worker must "know people,' ' and realize the 
significance of human relationships. She must 
be able to appraise the resources that are avail- 
able, and to grasp quickly the needs of a sit- 
uation. 

Encouragement should be given for what the 
parents are trying to do. Even capable persons 
become like children when over-strained or ill, 
and require advice and assistance to start a 
constructive program of action. The mother's 
point of view is based on experience with her 
own children, while the worker's ideas are the 
result of clinical training. This wider vision 
should be used to give clearer definition to the 
part the mother must bear in carrying out the 
child's program. 

Family Types. — The families with which the 
nutrition worker has to deal fall into two 
groups. The first, and fortunately by far the 
larger, seeks to cooperate and shows apprecia- 
tion of help in meeting difficulties that have 
proved too complicated to be solved alone. This 
group is made up of what we may call "good 

201 



NUTRITION AND GROWTH IN CHILDREN 

mothers, " while the second includes all those 
Who are, in one way or another, " difficult/ ' 

There is the stubborn, obstinate, and preju- 
diced type who does not really wish to learn. 
Others look for some one else to do the hard 
work, yet expect praise at every turn. Many 
are overindulgent, easygoing, and quite lacking 
in home control. Here we find the " spoiled 
child' ' and the spoiled mother as well! Others 
are simply lacking in common sense, and are 
irresponsible to such an extent that one can 
never "put his finger on them. ,, Still others 
are overanxious and fearful. There are always 
a few who are shiftless, vicious, or mentally 
deficient. The latter class includes many forms 
of subnormality which are menaces to the com- 
munity, and the nutrition worker should see that 
they are turned over to agencies having experts 
especially trained to care for them. 

To meet such problems the worker must have 
an understanding of human nature, and be able 
to grasp the strong and weak points in every 
situation. By some means each family with 
w r hich she has to deal must be controlled until 
there is a beginning of order and responsibility. 
The force of public opinion, school, church, and 
every other helpful factor must be brought to 
bear when needed. 

202 



THE NUTRITION WORKER 

In caring for families of this latter kind the 
worker must not neglect others of the first 
group with whom results can more readily be 
obtained. In one clinic several workers were 
exhausting their resources on a family in which 
the mother was found to be so mentally defec- 
tive that their efforts were largely wasted. 
Another mother had been on the roll of the same 
clinic for six years, receiving medicine from 
time to time but so little definite instruction that 
her children did not improve. This mother was 
intelligent and ready to cooperate fully. When 
she brought her children to the nutrition class, 
and received definite instruction as to their 
food and health habits, they went "over the 
top" ' in a few weeks' time. 

In one nutrition class we were told it was 
impossible to secure the attendance of the moth- 
ers. On investigation it was found that the 
nurses in charge were issuing orders for food 
and other supplies for these homes, and there- 
fore could have had the whip hand, although 
they were letting the mothers hold the club over 
them. As a result, the children in this clinic 
were averaging only 112 per cent of the ex- 



1 This expression is used to acknowledge the child's 
achievement when his actual weight line reaches the line 
representing the average weight for his height. 

203 



NUTRITION AND GROWTH IN CHILDREN 

pected gain in weight, while a few blocks away, 
where the cooperation of the mothers had been 
insisted upon, children from the same type of 
families were gaining at the rate of 369 per 
cent. 

Nutrition work has for its foundation the 
love of the parent for the child, but the nutri- 
tion worker, to be successful, must see that this 
natural affection is directed into the proper 
channel, and the parents held responsible for 
their part in every instance. 

Interest in Children. — All that the worker can 
do in the way of organization, administration, 
and teaching, however, counts for little unless 
she understands and cares for the children 
themselves. She must have a zeal for getting 
children well, guided by intelligence and a 
sense of proportion. These latter qualities are 
particularly important, for nothing is more dis- 
couraging than to spend one's self without stint, 
only to find that lack of essential knowledge 
has rendered all this labor unavailing. The in- 
domitable spirit which is bound to carry a child 
through to normal standards of health must not 
be allowed to waste itself through inadequate 
methods. 

There is also the danger that the worker may 
become so attached to a particular child that 

204 



THE NUTRITION WORKER 

she unconsciously seeks to keep him under her 
care rather than to use her best efforts to find 
out what it is that the child really needs. Cer- 
tain borderline mental cases show an excessive 
affection which appeals to the worker for an 
undue share of time and attention. All these 
complications should be considered in the light 
of the highest good of the individual and full 
justice to the whole group. 

The Appeal of Nutrition Work. — What is at- 
tracting high grade workers from other fields 
to this new form of service? The first answer 
is that there is real satisfaction in doing work 
that has results that can be definitely measured. 
The weight chart gives evidence that cannot be 
denied. "When the weekly weighing has been 
finished, the nutrition worker knows how many 
of the children are on the right track, and also, 
what is equally important, how many unsolved 
problems remain to challenge her best powers. 

Another aspect of the work is seen in the 
comment of a young college woman, * ' The work 
is so human!" The nutrition worker enjoys 
her association with mothers and children in 
the class group, and is as happy as they over 
the gains made. There is no greater satisfac- 
tion than that of seeing a sick child return to 
health. A malnourished child who has been 

205 



NUTRITION AND GROWTH IN CHILDREN 

retarded physically and mentally, a trial to him- 
self and his teachers, shows an actual trans- 
formation when he is brought to normal devel- 
opment. The improvement in his condition is 
reflected in the atmosphere of both home and 
school, and the nutrition worker may justly feel 
that her efforts have contributed to the welfare 
of the community. 

The opportunity that comes to the nutrition 
worker is as truly significant in saving life as 
that afforded by some dramatic surgical opera- 
tion. In setting children upon the road to 
health she is saving them from permanent 
physical unfitness and rendering a high form of 
public service. 









CHAPTER XIX 

THE PHYSICIAN AND THE NUTRITION CLASS 

A nutrition class is not conducted for diver- 
sion or amusement, for academic discussion, or 
for the purpose of philosophizing about the gen- 
eral value of health. It is a strictly business 
gathering, and the business to be accomplished 
is to get the children well. If this purpose is 
to be realized with anything more than ordinary 
efficiency, the physician should be present at 
every meeting. He need not spend more than 
half an hour with the class, for in that time he 
can bring out as many points as can be remem- 
bered. 

By the time the physician comes in, the nutri- 
tion worker has weighed the children, checked 
up the diet lists and the week's activities, given 
the stars for lunches and rest periods, and ar- 
ranged the children and their mothers in the 
order of the gains made. The charts are hung 
in a line in the same order, to show the physi- 
cian the progress made since his last visit. The 
class meeting is a vital feature of nutrition 
work, and presents a psychological opportunity 

207 



NUTRITION AND GROWTH IN CHILDREN 

in which much can be accomplished with a mini- 
mum of effort. 

The nutrition worker has had conferences 
with the parents and the children. She knows 
their problems, their efforts to overcome dif- 
ficulties, and, in many cases, the causes of fail- 
ure. The physician comes in as the final au- 
thority to observe the results of recommenda- 
tions previously made and to give further ad- 
vice as needed. 

He first notes the gains made, taking pains to 
give each child who has gained proper credit 
for his effort. The child is entitled to such 
praise as "That's a good record," "You have 
done well, ,, etc. These words should be spoken 
clearly so that all may hear and the child may 
feel that his efforts have been recognized. The 
children are thus encouraged to continue, and 
suggestions are made to help them increase 
their gain. Too much time must not be spent 
with this group, however, and the physician 
must pass on to those children who have not 
gained, usually about one-fourth of the total 
number. These present the physician's special 
problem. 

Where a child has not gained there is always 
a cause. This cause is either social, in which 
case the responsibility rests with the nutrition 

208 



THE PHYSICIAN AND THE CLASS 

worker, or it is medical, when it is the physi- 
cian's business to find it, and he has not ful- 
filled his duty until he has done so. In these 
cases he must carry his analysis further, ques- 
tioning both child and parent to see if directions 
previously given have been carried out, and 
going over again the five chief causes of mal- 
nutrition. 

Beginning with physical defects, he will re- 
ceive from the nutrition worker the report on 
the defects that have been corrected and those 
that remain to be done ; how many children are 
waiting for adenoid and tonsil operations, etc., 
and the reason for the delay in each case. This 
may be fear on the part of the parents or merely 
postponement until a more convenient time. 
He must convince the parents by the record of 
the charts and by all other available means of 
the necessity of having the defects corrected. 
Almost invariably the child who has not gained 
is found to be the child who has not followed di- 
rections. 

This leads at once to the question of home 
control, and perhaps the most essential part of 
the class work is with the mothers. If, for ex- 
ample, the child has not taken his rest periods 
we ask the mother why, and tell her she is re- 
sponsible for this part of the program, and in 

209 



NUTRITION AND GROWTH IN CHILDREN 

fact for all directions given that are to be car- 
ried out in the home. These will cover most of 
the points relating to overfatigue and the 
child's food and health habits. The mother 
must be convinced of her responsibility in get- 
ting her child well, and should not be lightly 
excused for failure to follow directions. She 
must be shown that by obeying instructions she 
is not only preventing sickness, but possibly 
saving her child's life. 

Where directions have not been followed, it 
is remarkable what effect the public opinion of 
the group has on the delinquent mother. She 
rarely has the moral courage to continue coming 
to the class without making the changes recom- 
mended in her child's program, knowing that 
this will be brought to light in case there is 
failure to gain. 

A convincing demonstration is given when a 
child who has gained is asked to stand up before 
the group with a child who has not gained. The 
mothers learn to notice improvement from week 
to week with almost the same keenness as the 
doctor and when one mother sees the results 
secured by another whose child has carefully 
followed instructions, the result is apt to be 
very different in the case of her own child the 
following week. 

210 




Figure 32. the child as ax object lesson 



Those two sills, Margaret and Irene, afford a comparison of results. 
Margaret had stopped drinking tea. had taken her lunches and rest 
periods faithfully and followed all directions, with a consequent sain of 
1 Mi pounds, which placed he' at the head of the class for the week. 
Irene, who stands at the right, was at the foot of the class because 
sue nau failed to gain. Her mother was afraid she would take cold if 
her windows were open at night. She was allowed to select her own 
food and to indulge in "banana splits" between meals. Seeinir the 
gains made by the other children, her mother agreed to have the 
windows opened, and Irene corrected her had food habits. 
The following week she made a good sain. 



THE PHYSICIAN AND THE CLASS 

The physician should not take this occasion 
to lecture or to give general advice. Each point 
brought out should be demonstrated by the 
weight chart and by the child himself. In this 
way teaching is done by example and by visual- 
ization, which is perhaps the most effective 
method of education. 

There is a fine spirit of truthfulness and 
honor in the nutrition class and the relation be- 
tween the children and the physician becomes 
one of mutual trust and cooperation. The de- 
sire to gain is so keen that their attitude is, 
"What can I do?" and "How can you help 
me?" 

Points are brought out in these class meetings 
that would never be discovered otherwise. For 
example, a boy who had not gained asked if 
reading in bed before breakfast would interfere 
with his gaining ; a little girl said she slept with 
windows closed for fear a cat would get into her 
room at night ; another child had been kept after 
school to help correct examination papers ; and 
we frequently find a child attending daily re- 
hearsals for entertainments when he is already 
suffering from overfatigue. 

The children are always interested in one 
another, and the mothers become interested in 
every child in the class ; thus all learn from the 

211 



NUTRITION AND GROWTH IN CHILDREN 

general experience, provided the physician 
brings out each point clearly. 

With the indifferent mother the physician 
must be skillful in appealing to the influence to 
which she is most susceptible. In one case it 
may be her love for the child and her desire to 
have him well ; in another, public opinion may be 
the most potent lever ; another mother may be 
reached through a sense of shame in seeing her 
child at the foot of the class; others are flat- 
tered by receiving the attention of the physician 
and the nutrition worker, but all have a feeling 
of pride and satisfaction in seeing any child 
in the class return to health. 

The questions asked should be definite 
and definite answers should be required. 
"Why have you not taken your rest periods f " 
Certain mothers need to be addressed in a thor- 
oughly businesslike manner. "Do you want to 
play this game or not?" "If you don't in- 
tend to obey instructions, do not bring your 
child in again." "Does health mean more to 
you than education, or do you value education 
more than health?" "If you think your child's 
health the more important, then do not talk to 
me any more about promotions or what he is 
missing in school. He has all his life to study 
but only a few years to grow." 

212 



THE PHYSICIAN AND THE CLASS 

The nutrition class aids the mother in estab- 
lishing control over her child. When the boy 
or girl wants to get well, and the program 
recommended to accomplish this calls for plenty 
of sleep, regular meals, and the correction of 
faulty food and health habits, the occasion for 
parental discipline in these matters is removed 
and the problem of home control is greatly 
simplified. Therefore, when directions are 
clearly given to the mother in the presence of 
the child, and we explain to both the absolute 
necessity of their being followed, they return 
home with an equal desire to carry out the pro - 
gram and get results. The child will now work 
with the mother in the same way in which a 
good soldier promptly obeys an officer who has 
learned to give the proper orders. In each case 
the problem of discipline is largely eliminated. 

So helpful has the class been in improving 
home control that we have been asked re- 
peatedly by mothers to continue the classes dur- 
ing the summer for this reason alone. 

On several occasions I have hesitated about 
holding a class meeting in especially bad 
weather, but on telephoning to inquire about 
the attendance have found it to be practically 
normal. When once aroused to the importance 
of the class, neither mother nor child will allow 

213 



NUTRITION AND GROWTH IN CHILDREN 

anything to interfere with their attendance. 
One mother brought her boy of seven to the 
class by carrying one child in her arms and ar- 
ranging with a neighbor for the care of another. 
To reach the class on time she was obliged to 
rise at five in the morning but rarely missed 
a meeting during two whole winters, although 
on some days the thermometer was below zero. 
The power for health that may be generated 
in such a class through the combined efforts of 
physician, nutrition worker, parent, and child 
is remarkable. 



CHAPTER XX 

REPORT OF A CLASS MEETING 

To illustrate what can be taught in less than a 
half hour's time by means of the nutrition class, 
the following report of a recent meeting is 
given. This class is connected with a nutrition 
clinic at a large hospital, and is selected, not be- 
cause of exceptional results, but because it pre- 
sents rather more than the usual number of 
problems, and the group is largely from a neigh- 
borhood in which strong cooperation of the 
schools is lacking. 

The attendance on the day of this meeting 
was fourteen children and nine mothers. The 
class had been organized only a few weeks, and 
was being gradually increased. Four new chil- 
dren came in with their mothers for the first 
examination, and two others had been sent for 
examination from other departments of the hos- 
pital, only eight having previously been regu- 
larly admitted to the class and given charts. 
These eight were seated according to their 
gains in the following order : 

1. Florence Z. (age eleven, 17 per cent un- 
215 



NUTRITION AND GROWTH IN CHILDREN 

derweight) occupied the seat of honor at the 
head of the class, having gained one and one- 
half pounds. She had taken her lunches and 
rest periods without missing a single day, and 
was pleased to stand up that the other children 
and the mothers might see her improvement, 
which was evident in her general appearance 
and better color. Her mother said, "I chase 
her to bed since coming here." 

2. Morton B. (age fourteen, 10 per cent un- 
derweight) gained one and one-quarter pounds. 
This boy's stepmother had been unwilling to 
have him excused from school for his mid-morn- 
ing lunch and rest period, but as this meeting 
was during vacation he had taken both faith- 
fully. As his previous average gain h,ad been 
only two ounces, this week's record of twenty 
ounces was conclusive evidence to the mother of 
the significance of overfatigue from school 
work. She therefore asked for a note to have 
Morton excused from school at 10:30 that he 
might continue his mid-morning lunch and rest 
period. 

3. Stephen B. (age thirteen, 17 per cent un- 
derweight), who gained one and one-quarter 
pounds, was a newsboy and particularly active. 
He had previously thought it not worth while 
to go to bed early because he could not fall 

216 



A CLASS MEETING 



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Muriel M. had been following all directions for eight weeks without 

making progress towards her normal weight line. Following a visit 

to the class, her teacher excused her at 10:30 for a mid morning 

rest period. The subsequent gain confirmed the diagnosis 

of overfatigue from too long school hours. 

asleep at once, and had therefore been staying 
up as late as 11 or 12 o'clock at night. When 
it was explained to him that he conld rest even 

217 



NUTRITION AND GROWTH IN CHILDREN 

when not sleeping, he agreed to take more rest 
and the week's good gain proved that this was 
clearly a case of overfatigue from late hours. 

4. Rose H. (age nine, 5 per cent under- 
weight) gained only one-quarter of a pound, 
which had been her average gain for four weeks. 
She had been advised to have an adenoid and 
tonsil operation, and her small gain, although 
all directions had been faithfully followed, con- 
firmed earlier evidence of the harmful effect of 
her diseased tonsils. An appointment was ac- 
cordingly made at once for the operation. 

5. Muriel M. (age twelve, 5 per cent under- 
weight) had not gained, although she had tried 
to follow instructions. Her mother had been 
ill with pneumonia, and Muriel had been doing 
extra w r ork at home. Her teacher visited the 
class this morning, and seeing Muriel 's chart 
and having her condition demonstrated, prom- 
ised to adjust the child's school program so 
that she might be excused at 10 :30 for a lunch 
and rest period until she reached normal 
weight. (See Figure 33.) 

6. John D. (age seven, 10 per cent under- 
weight) also failed to gain, and the nutrition 
worker found the cause here was lack of 
home control. The mother remarked with little 
apparent concern that John did not mind her 

218 



A CLASS MEETING 

when she called him in from play. She was 
then asked the following questions : 

"Who runs your home, you or your husband?" 
Answer. "My husband gives me the money, and I 
run the house. ' ' 

"How much does your boy weigh?" Answer. 
"Forty pounds." 

1 ' How much do you weigh ? ' ' Answer. • ' One hun- 
dred and forty pounds." 

"Do you mean to say that you, who weigh 140 
pounds, cannot control your boy of seven who weighs 
only 40 pounds?" Answer. "Of course I can make 
him mind." 

"Then, Mrs. D., why don't you make him come in 
for his rest periods ? " No answer. 

The physician continued : 

"There is no use in your boy coming here week 
after week unless there is some one in authority over 
him with whom I can do business. If you can run 
your house, you should be able to make your boy 
mind. I suggest if John goes out to play and fails 
to come in at the proper time, that you go after him 
and keep him in until he promises to obey you. We 
depend on you to follow directions. ' ' 

The mother promised "to attend to him ,, the 
following week. 

7, Alfred H. (age eleven, 17 per cent under- 
219 



NUTRITION AND GROWTH IN CHILDREN 

weight) weighed just the same as at the last 
meeting. He had been a very difficult problem 
case for more than three years, with no relative 
gain in weight. His continued failure to gain 
indicated that there was some serious underly- 
ing cause. Five consultations had been held, 
and much laboratory work performed without 
success in determining the real cause of his 
poor condition. The preceding week a radio- 
graph of the digestive tract had been made, and 
Alfred had come in to hear a report of the ex- 
amination. The results showed signs of possi- 
ble intestinal adhesions, and arrangements were 
accordingly made to send the boy to the hospital 
for treatment. 1 (See Figure 7.) 

8. Thomas M. (age twelve, 15 per cent un- 
derweight) had lost one-half pound. He was 11 
pounds under the average weight, but his 
mother thought if he were in bed 12 hours at 
night, he did not need extra rest during the day. 
She was reminded that the average well man 

1 Further tests and examinations in the ward confirmed 
the Roentgen-ray findings, which evidence, supported by 
the long failure to gain under otherwise favorable condi- 
tions, led to the decision to make an exploratory abdominal 
operation. This operation showed bands across the du- 
odenum (probably congenital) that adequately 3xplained 
his poor nutrition. He is now gaining steadily, and on the 
road to complete recovery. 

220 



A CLASS MEETING 

found 8 or 9 hours' work a day sufficient, 
and told that she should not allow her under- 
nourished boy to expend his energy for 12 con- 
secutive hours practically without rest. She 
promised to have him take a half hour's rest 
before both dinner and supper, and mid- 
morning and mid-afternoon lunches at a regular 
time. 

Thus by bringing into play the four forces 
that safeguard the child's health, namely, the 
home, medical care, the school, and the child's 
own interest, a single meeting of the nutrition 
class produced results in a space of less than 
30 minutes that it would have required hours of 
individual work to accomplish. 



CHAPTEB XXI 

THE NUTRITION OE DIAGNOSTIC CLINIC 

In nutrition work we are constantly meeting 
children who have been the subject of extensive 
medical study without showing marked im- 
provement. They may have been under the 
care of various child-helping organizations, and 
have passed through several hospital depart- 
ments. Even after the thorough physical- 
growth, mental, and social examinations of the 
nutrition class, there will always remain a cer- 
tain number of children who do not respond to 
treatment, and whose charts after weeks and 
even months show practically no gain in 
weight. Such cases are a drag on the class, and 
if they are in too large a proportion to the total 
number, there results discouragement and lack 
of interest on the part of the whole group. 

The nutrition class is not only a helpful means 
of treatment, but also an aid in securing correct 
diagnosis of these difficult cases. The failure of 
growing children to gain when all the known 
causes that would interfere with their progress 
have been eliminated is a significant indication 

222 



THE NUTRITION CLINIC 

that there is some physical cause that has been 
previously overlooked. The child who does not 
gain under such conditions is most probably 
not "free to gain," and after a trial of four or 
five weeks in the nutrition class, should be sent 
to a nutrition, or diagnostic, clinic. 

Such a clinic is most effective when connected 
with a hospital, where all the resources of that 
institution may be called into service if neces- 
sary. The clinic should work in close coopera- 
tion with the various specialists on the hospital 
staff, and secure special tests and expert advice 
according to the needs of the individual child. 
Observation over a number of months is some- 
times necessary and Roentgen-ray, Wasser- 
mann, von Pirquet, skin proteid tests, and much 
laboratory work may be required before the 
correct diagnosis can be made. Among the ob- 
scure causes of malnutrition thus found in the 
diagnostic clinic may be mentioned cardio- 
spasm, anaphylaxis, chronic appendicitis, in- 
testinal parasites, pyelitis, hereditary syphilis, 
tuberculosis, and sinus infection. 

The nutrition clinic should be an important 
department of the children's out-patient depart- 
ment of every hospital, with a nutrition class as 
part of its organization, for the purpose of ob- 
serving the child under controlled conditions. 

223 



NUTRITION AND GROWTH IN CHILDREN 

In order that it may operate effectively, it must 
be a rule of the hospital that all children who 
apply for treatment shall be weighed and meas- 
ured, and those found to be underweight sent 
to the nutrition clinic automatically. The nu- 
trition clinic serves a fourfold purpose : 

1. It relieves the special departments by tak- 
ing care of simple cases of malnutrition in its 
nutrition class. 

2. It gives opportunity to study problem 
cases sent in from nutrition classes in neighbor- 
ing schools and community centers, and directs 
the progress of unsolved cases from one depart- 
ment of the hospital to the other. The com- 
pleteness of its history and examination form 
assists the special departments by supplying 
data that aid in their diagnosis and treatment. 

3. It offers a demonstration in first-hand 
health instruction to parents, teachers, students, 
social workers, nurses, and physicians. 

4. It acts as a clearing house for children 
who most need the benefit of summer camps, 
outings, or institutional care. 

The attendance of the parents is necessary 
at every meeting of the nutrition clinic. When 
both parents are present the diagnosis is fre- 
quently made clear at once. Their observation 
of the child in his normal environment at home 

224 




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THE NUTRITION CLINIC 

may be more illuminating than that of specially 
trained observers in the unaccustomed sur- 
roundings of ward or institution. 

When the attendance of the father is re- 
quested, the usual answer is that he cannot 
leave his work. Before such a reply is ac- 
cepted, the matter should be taken up with 
his employer, who should welcome this as an 
opportunity to establish more human relations 
with his employee by making such adjustments 
as may be necessary to allow him to be absent 
an hour a week to help his child to get well. 
When the importance of such cooperation is 
fully explained, the case is rare where it cannot 
be secured. 

A useful adjunct to such a diagnostic clinic is 
a nutrition camp or station under its control, 
where children may be sent to note their reac- 
tion to changed environment when it is sus- 
pected that the causes of their malnutrition 
are social rather than medical. Such a camp is 
more useful for diagnostic purposes than a bed 
in a hospital, provided the child is under the 
observation of a trained nutrition worker who 
can note the child's reaction to his surround- 
ings, to other children, and to the authority of 
the camp. All this is valuable evidence for 
mental and social as well as for physical diag- 

225 



NUTRITION AND GROWTH IN CHILDREN 

nosis. Cases whose diagnosis has remained ob- 
scure for weeks and months in the nutrition 
class and the hospital often become clear in a 
few days under such controlled observation. 1 

When admitted to the camp, the children 
should be accompanied by their parents, who 
should also make regular visits at the time of 
the weekly weighing, in order that they may 
understand thoroughly just what is being done 
for their child, and so continue the treatment 
when he returns home. 

Children frequently gain four or five pounds 
in a single week at such a camp, even though 
they are given no more, and no better, food 
than they were taking at home. This is a con- 
vincing demonstration to the parents that the 
regular routine with its rest periods, mid-morn- 
ing and afternoon lunches, and freedom from 
disturbing influences, is the cause of the child's 
improvement, and that the same program car- 
ried out at home will continue the good accom- 
plished. 

It must be borne in mind that the responsi- 
bility for the child's health always rests with 
the parent, and therefore all efforts should be 



1 In Figure 44 we show the results accomplished in such 
a camp at Grand Rapids, Michigan. 

226 



THE NUTRITION CLINIC 

directed towards helping the parents in their 
work, not even temporarily taking such respon- 
sibility from their hands. Too often a child is 
given special privileges in an open-air school 
or camp with a consequent improvement in his 
condition, only to return to improper diet and 
faulty health habits that in a short time reduce 
him to his former poor condition. The health 
education that comes to the parent through ob- 
servation of the steps taken in arriving at a 
correct diagnosis is a great factor in making 
the child's recovery permanent. 



CHAPTER XXII 

MALNUTRITION AND THE SCHOOL 

Educators have long sought a means of bring- 
ing home and school into closer association. The 
nutrition class accomplishes just this result. 
Attendance of the parents at the weekly class 
meetings brings them into friendly relations 
with one another and with school and health 
authorities. In the purpose of making the chil- 
dren well they are united in an atmosphere of 
mutual helpfulness, which promotes a better 
understanding of the spirit and administration 
of the school. 

Parents are appreciative of what the school 
brings to the child in the way of culture and 
opportunity, but when it is also the agency 
through which the undernourished child be- 
comes well and strong, this feeling is intensi- 
fied into gratitude, and such a school commands 
the highest loyalty of its graduates and their 
parents. 

Effect of Malnutrition. — Children who are 
malnourished react abnormally, and suffer 
greatly from pressure and nagging. This 

228 



MALNUTRITION AND THE SCHOOL 

makes them either callous and indifferent to 
influences that are needed in their develop- 
ment, or, in the effort to keep pace with their 
class, leads to disheartening and destructive 
overfatigue. The effect of this condition, more- 
over, is not confined to the malnourished pupils 
themselves. Such children become a drag on 
the class, and despite all efforts of the school 
authorities, there is a constant tendency to 
lower standards. While those who are unfit 
for the struggle are still under strain, the chil- 
dren who are well able to do full work suffer 
from not being kept up to their normal capac- 
ity. 

It is a well recognized fact among physicians 
that school teachers as a class break down more 
frequently than do members of any other 
profession. Many teachers are only malnour- 
ished children grown up, without ever having 
had knowledge of what the full tide of health 
means. They have no surplus energy, and 
would profit by the nutrition program that is 
provided for their pupils. Their nervous ten- 
sion is constantly reflected in the health of 
their charges, while the malnourished children 
in turn react on the overstrained nerves of 
their teachers. The reduction of malnutrition 
will therefore lessen the burden of both teach- 

229 



NUTRITION AND GROWTH IN CHILDREN 

ers and pupils, and greatly increase the effi- 
ciency of the school. 

Extent of Malnutrition. — One-half of the chil- 
dren in public and private schools are seriously 
underweight, and at least one-third are mal- 
nourished. Very seldom does a school show 
less than this proportion, and in some cases the 
malnutrition amounts to 60 per cent. An ex- 
amination of the entire enrollment of one of our 
leading private schools, one that has influenced 
schools abroad as well as in this country, dis- 
closed the fact that over one-third of the pu- 
pils were more than seven per cent underweight 
for their height, and had other unmistakable 
signs of malnutrition. This means that even in 
the homes of unusually intelligent and thought- 
ful people retarded growth has been unappreci- 
ated and uncared for. 

The Nutrition Program in the School. — To 
combat this widespread condition the nutrition 
program should begin with the first day of the 
child's attendance. No child should be admitted 
without a complete physical examination in the 
presence of both his parents. The situation is 
serious enough to warrant the few minutes of 
concentrated attention necessary at this time 
in order to save the loss to the community of 
large numbers of backward pupils in all the 

230 



MALNUTRITION AND THE SCHOOL 

grades, and from 30 to 40 per cent of physically 
unfit children among the graduates. 









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FlGUBE 35. SCHOOL EXAMINATIONS 

Buring the week of examinations school children almost invariably 
lose from % to 2 pounds in weight. 

Every pupil should be weighed and measured 
once a year and re-weighed once a month. As 
there will always be a certain number of chil- 

231 



NUTRITION AND GROWTH IN CHILDREN 

dren absent at the time of the weighing, a sys- 
tem should be inaugurated by which these chil- 
dren will be weighed immediately upon their 
return. If cards for all the pupils in each room 
are made out in advance, the person in charge 
of the weighing will be able to keep track of the 
absentees and check up their records when they 
appear. There should be a set time, prefera- 
bly at the opening of school in the morning, 
when these children are sent to the room where 
the weighing and measuring is done. 

This follow-up work with absent children is 
the more important because this group is cer- 
tain to contain a large percentage of children 
whose absence is caused by malnutrition or by 
acute illness which is apt to lead to this condi- 
tion. The gain or loss revealed by the weighing 
on the child's return to school should be the test 
by which it is determined whether or not he is 
ready to resume full work. No child who has 
been absent on account of illness for more than 
a single day should be allowed to undertake a 
full program until he has regained his lost 
weight. 

Nutrition classes should be formed of the 
worst cases, beginning with the children who 
are 10 per cent or more underweight. As the 
first members graduate, their places may be 

232 



MALNUTRITION AND THE SCHOOL 

filled by children less than 10 per cent under- 
weight, and in this way the program can be 
extended to include even the borderline cases — 
those less than seven per cent below the average 
weight for their height. 

The School Physician. — The physician for 
this work should be trained and experienced 
in growth standards. At present, with one ex- 
ception, the subject of malnutrition is not 
taught in our medical schools. For this reason 
the school physician requires ispecial instruction 
and supervision in nutrition work. 

The physician must have the final authority 
to decide what program is best for the mal- 
nourished child. He is responsible for the 
health of the child, and must have authority 
commensurate with his responsibility. The 
teacher and principal must defer to his judg- 
ment whenever questions arise as to the amount 
of time a child may be in school or the amount 
of work he is able to do. fc 

The Nutrition Clinic. — Each nutrition class 
should have direct relation with a nutrition, or 
diagnostic, clinic where all cases that fail to re- 
spond to treatment will be sent for further in- 
vestigation by specialists. An important func- 
tion of the nutrition clinic is to make one or 
more special classes serve as a clearing house 

233 



NUTRITION AND GROWTH IN CHILDREN 

where obscure cases may be under observation 
for a sufficient length of time to ensure a thor- 
ough understanding of their condition. 

In like manner, the malnourished children 
who require special hours and additional care 
may be grouped together in open-air or special 
classes, where they can be provided for without 
unduly complicating the programs of the nor- 
mal classes. Children should not be placed in 
these special classes until they have been made 
"free to gain." Otherwise, there is danger 
that the classes will become congested with 
children who fail to make progress, and keep 
others from an opportunity for observation and 
treatment. 

There should be rigid adherence to the rule 
that if children are to have the special privilege 
of open-air schools or classes, the parents 
should cooperate by having defects removed 
promptly and by regularly attending the class 
meetings until their children become well. 

School Hours. — It is easy for school authori- 
ties to forget that no amount of education can 
compensate for loss of health, and that it 
is better for a child to work part of the day in 
prime condition than to spend double the 
amount of time dragging over his lessons in a 
state of overfatigue. On the other hand, the 

234 



MALNUTRITION AND THE SCHOOL 

physician does not always remember how short 
a time many children are in school before they 
leave to go to work. Nor does he always appre- 
ciate the discouragement that comes to a child 
when he falls behind his grade and loses step 
with his mates. The child's day should be so 
planned that he may accomplish maximum re- 
sults in the business of education. 

Schools in several communities are already 
giving credit for properly conducted rest pe- 
riods, and it is certainly just as reasonable to 
credit rest, when this is what the child needs, as 
it is to credit gymnastic exercise, which often 
overtaxes the child, and, instead of promoting, 
may interfere with, his growth and health. 

Adjustment of the Schedule. — Malnourished 
children cannot work profitably upon a full 
school program, and the results of attempting 
to do so may be serious to their health. In 
many instances they can meet the requirements 
up to the time of recess, if they are then al- 
lowed to go home for a lunch and rest period. 
This w T ill bring them back rested and refreshed 
for the shorter afternoon session. By a simple 
modification of the school program some minor 
subject of study can be scheduled for the latter 
part of the morning, which will relieve the pres- 
sure on all the pupils, and enable the malnour- 

235 



NUTEITION AND GROWTH IN CHILDREN 

ished to keep up with their grade even with a 
temporary absence at this time. 



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Figure 36. school half day 

An immediate gain was made by John B. when he was taken out 

of school for half a day. Even better than this is the cutting down 

of the long morning session by excusing the child for a lunch and 

rest period at 10 :30. He can then return rested for 

the shorter afternoon session. 



One-session schedules not only necessitate 
close application for a long period of time, but 
also place heavy responsibilities for home study 
upon the pupils. They make it harder to give 

236 



MALNUTRITION AND THE SCHOOL 

children a reasonable program for meals 
and outdoor life. Nevertheless, there are many 
cities that keep children in school continuously 
from 8 :30 to 1 :30 or 2 :30, with only 20 minutes 
intermission for lunch. 

When children are within easy range of the 
school building, 8:45 is a good opening hour, 
and will allow plenty of time for breakfast and 
toilet without hurry. At 10 :15 there should be 
a 20-minute rest, and the air should be changed 
throughout the building. At least an hour and 
a half should be allowed for the noonday meal. 
This is particularly important in winter in or- 
der that the children may have some time in the 
open air during the hours of sunlight. If the 
afternoon session begins at 1:15, there should 
be another break about 2 :30 and school should 
close by 3 :30. 

This is a program for the normal well child. 
For the malnourished the schedule after 10:15 
should be 10 minutes for lunch, 15 minutes in 
the open air, and half an hour for a rest period 
lying down. The lunch and rest periods should 
not interfere with the child's usual playtime. 
Play is necessary for the malnourished child, 
but should be supervised to prevent overexer- 
tion. 

The recess periods should be occasions for 
237 



NUTRITION AND GROWTH IN CHILDREN 

real recreation, and not used as a means of 
punishment or a time for additional cramming. 
Many children need fully as much to be taught 
how to break away from their studies and get 
out in the open, as to study and recite lessons. 
A change in subject or classroom is chiefly a 
change from one form of pressure to another, 
and does not provide sufficient relief. 

The kindergarten is mainly valuable for the 
opportunity it affords the child to sense a big- 
ger world than that to which he has been accus- 
tomed. Here, too, he meets the discipline that 
comes from active contact with other children 
of his own age, and is required to make adjust- 
ments that come about less naturally in the life 
of the home. It is neither necessary nor de- 
sirable that he should spend many hours daily 
in this new environment, and the child profits 
by a gradual transition from short school hours 
at the beginning to the fairly long day required 
during adolescence. 

Adjustment of the Program. — Children should 
be considered as individuals and not merely as 
members of a group, grade, or class. This is 
especially true of convalescent or malnourished 
boys and girls. Failure to regard this princi- 
ple is responsible for many of the misfits and 
failures among children who, with a better un- 

238 



MALNUTRITION AND THE SCHOOL 

derstanding of their individual needs, might be 
trained to lives of usefulness and satisfaction. 

The taste of success is necessary to either 
mental or physical progress. Discouraged by 
their inability to meet the requirements imposed 
on the whole group, many children fail to de- 
velop the latent ability they possess, which 
would be brought out by tasks suited to their 
capacity. Instead of laying sound foundations 
for the future years of effort and strain, the 
school sends them forth with a lack of confi- 
dence and a consciousness of failure which they 
may carry through life. 

Health Education. — After the child is relieved 
of tasks beyond his strength, and the school 
program is adjusted on the basis of conserva- 
tion rather than exploitation, there is still much 
valuable work that can be done by the school 
through the nutrition program. We hear much 
about " problem' ' and " project" work in the 
schools. Where can one find problems and proj- 
ects that appeal more directly to the child than 
those that have to do with bringing himself up 
to normal health, where he will be able to take 
his full share in the life about him, in its sports 
as well as its studies? 

The details of the nutrition class offer train- 
ing in observation and careful record making. 

239 



NUTRITION AND GROWTH IN CHILDREN 

Through the weekly diet record a knowledge of 
food values and food constituents is gained, 
which is as deserving of academic credit as 
any other subject studied, while the discussion 
of food and health habits has a practical educa- 
tional value greater than any abstract course 
in physiology or hygiene. 

The nutrition program provides a check upon 
malnutrition from the time the child enters 
school to the end of his connection with it. With 
parents informed, instructed, and brought into 
relations of cooperation with the school au- 
thorities from the start, the efficiency of the 
whole student body is raised, and great waste 
and loss saved to the community. It should be 
impossible under this program to have such 
conditions as now prevail even in high schools, 
where from one-third to one-half the pupils are 
unfit for their work, worried about examinations 
and promotion, and graduate physically unfit 
to begin their real work in life. 



CHAPTER XXIII 

SCHOOL LUNCHES FOR MALNOURISHED CHILDREN 

School feeding is no panacea for malnutri- 
tion. A common fallacy in urging the estab- 
lishment of school lunches is the belief that the 
problem of malnutrition is mainly one of diet. 
As already pointed out, however, only one of its 
five chief causes is concerned with food, and a 
child who is suffering from physical defects, 
lack of home control, or overfatigue cannot be 
brought to normal condition by merely supply- 
ing him with extra food at school. 

It is as futile to plan the school lunch without 
regard to the other meals of the child as to give 
an infant one feeding of carefully modified milk 
and allow him whatever he likes at other times. 
With due regard for the other needs of the 
child, however, school feeding can be made a 
useful part of a well balanced nutrition pro- 
gram. There should be an extension of the 
school-lunch movement to include at least such 
simple features of our nutrition program as the 
regular weighing and measuring of the chil- 

241 



NUTRITION AND GROWTH IN CHILDREN 

dren, and the checking of their diet by means 
of the 48-hour record each week. 

For pupils who are unable to go home for the 
noon meal a substantial lunch of about 800 cal- 
ories should be supplied. A soup or a hot drink 
should always be provided during the winter 
months. 

A mid-morning lunch of about 300 calories is 
needed by every malnourished child, and should 
be made available to all at cost. Provision 
should be made privately for indigent children 
who are malnourished. Suitable foods for 
these lunches are thick soup and crackers, bread 
and milk, or sandwiches and cocoa. No sweets 
should be furnished at this time as they tend 
to spoil the appetite for the next meal. 

The mid-morning lunch is particularly valu- 
able because it breaks the strain of the long 
morning session, and removes the sensation of 
hunger, which is apt to be felt during the latter 
part of the morning. As breakfast is usually 
the poorest meal of the malnourished child, the 
middle of the morning is the time when extra 
feeding is most needed. 

As has been stated, the child will assimilate 
more food in five light meals than in three heavy 
ones. In fact, various experiments with chil- 
dren in an institution where full control was 

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Figure 37. the value of lunches 

This boy was making rapid progress towards his normal weight 

line, when his mid-morning and mid-afternoon lunches were omitted. 

The result was no gain for the week, although his diet list 

showed an increase in the total amount of food taken. 

243 



NUTRITION AND GROWTH IN CHILDREN 

possible have shown that they gained faster 
when given five meals a day of a lower total 
valne than the cnstomary three meals, npon 
which there had previously been no increase in 
weight. 

A Comparative Study. — In an experiment 
made in Public School 64 in New York City x 
five groups of children were studied. Three of 
these followed our nutrition program, including 
a rest period and lunch at school in the morning 
and at home in the afternoon ; the fourth group 
was able to carry out only part of the program, 
and the nutrition class exercise was held under 
adverse circumstances ; the fifth group was fur- 
nished a noon lunch of about 1,200 calories daily 
with no other treatment. At the end of 10 weeks 
it was found that the fourth group had made 
twice the gain of the fifth group, while the three 
classes that had followed the full nutrition pro- 
gram, but had not been supplied with a noon 
meal at school, did five times as well as the fifth 
class with its extra feeding. 

Unfavorable Conditions. — The school lunch 
has unfortunately been introduced in many 
schools where an appreciation of the elements 



1 "A Nutrition Clinic in a Public School." (Pamphlet 
No. 1, in List of Publications, p. 332.) 

244 



SCHOOL LUNCHES 

of hygiene is lacking. A dark basement room 
is frequently assigned; the children have no 
opportunity to wash and dry their hands prop- 
erly; they are compelled to stand in line waiting 
to be served; seats are not provided; and a 
teacher or janitor hurries them in their eating 
so that the room may be cleared for other pur- 
poses. This friction and strain result in fa- 
tigue, which offsets the benefit of the food pro- 
vided. 

An Educational Opportunity. — On the con- 
trary, it should be recognized that this is a fav- 
orable opportunity for teaching food values and 
proper food habits. The children should be 
seated, and allowed ample time for eating with- 
out hurry. They should have clean hands and 
paper napkins. There should be as little han- 
dling of the food as possible, either by those 
serving or by those served. This is important 
because of the many serious diseases that are 
communicated by the mouth. Sandwiches can 
be eaten from the papers in which they are 
wrapped, and milk taken through straws direct 
from the bottle. 

The morning lunch should not be allowed to 
interfere with the open-air recess, because chil- 
dren need a complete change from the class- 
room conditions at every intermission. The 

245 



NUTRITION AND GROWTH IN CHILDREN 

lunch period should be a recognized part of the 
school schedule, and should be supervised by a 
nutrition worker or by the teacher in charge 
of the weekly weighing and the checking of the 
diet lists. Valuable observations can be made 
at this time as to the tastes, habits, and re- 
actions of the child. The malnourished chil- 
dren should be formed into groups large enough 
to gain the benefit of suggestion, comparison, 
and competition, but small enough that atten- 
tion may be given to each child's needs. 

The complaint is often heard that many pu- 
pils will not eat the good food provided for 
them. These objections are usually based on 
first impressions. Children are naturally con- 
servative, and are slow to make changes in 
their accustomed diet, but the association with 
other children who do care for the new food 
will soon have its influence. Eeports of these 
lunches are carried home by the pupil, and thus 
bring about changes in the family diet that it 
would be difficult to effect through other 
channels. 

Obstacles to Progress. — In a model school in 
Chicago where our nutrition program is now in 
force, mid-morning, noon, and mid-afternoon 
lunches were served under most favorable con- 
ditions, and rest periods were also provided, 

246 



SCHOOL LUNCHES 

yet the children gained the least of 20 similar 
groups in other parts of the city. The first 
case investigated was that of a girl who had the 
habit of reading in bed with a droplight until 
one or two o 'clock in the morning. Under such 
circumstances no amount of extra feeding would 
cause her to gain properly. 

The mother of the next child was an active 
member of the Parent-Teacher Association 
which had undertaken the nutrition program. 
Her boy was following all the instructions given, 
but he had become over-enthusiastic about 
physical training, and by too much exercise was 
making worse a bad condition of overfatigue. 

Many of the children in this group either ate 
a very scanty breakfast or omitted it entirely, 
knowing they would have their lunch at school 
in the middle of the morning. The school pro- 
gram in this case was ideal, but there was the 
essential fault that the program for the rest 
of the day was not controlled. By insisting that 
the parents come in each week, thus checking 
up the home conditions of the child, such facts 
as those mentioned are soon brought to light. 

In another city a boy whose school program 
had been lightened, and for whom rest and lunch 
periods were provided, still failed to gain in 
weight. It was some time before we found that 

247 



NUTRITION AND GROWTH IN CHILDREN 

he was taking long swims in cold water. 
Another boy in the same class continued to 
drink tea, although he obeyed all other direc- 
tions. Both boys knew in a general way that 
what they were doing was injurious, and they 
were careful to conceal the fact from the nutri- 
tion worker until their own interest was suffi- 
ciently aroused to cause them to sacrifice their 
inclinations for the sake of good health. 

These cases are cited to show that until the 
central difficulty in each case was removed, the 
extra feeding failed to benefit the children. In 
spite of the difficulties to be overcome, however, 
the school lunch is nevertheless an important 
adjunct of the nutrition program, and when 
properly served has great educational possi- 
bilities. 



CHAPTER XXIV 

INSTITUTIONS AND THE SUMMER CAMP 

In an institution where children are under 
full control day and night it should be possible 
to eliminate malnutrition entirely, and the pres- 
ence of a malnourished child among those who 
have been in the institution a sufficient time for 
study and treatment requires explanation. 

The steps necessary to inaugurate the nutri- 
tion program in an institution are the same as 
those outlined for use in schools, namely : weigh- 
ing and measuring; complete physical-growth 
examination upon entrance; grouping of the 
malnourished in nutrition classes; follow-up 
work to make the children "free to gain;" ad- 
justment of the individual programs so that 
each schedule will be suited to the strength of 
the child. 

In one of our leading cities the nutrition pro- 
gram was undertaken in two institutions for 
the care of orphans, which appeal for support to 
much the same group of public-spirited citizens. 
When the children were reexamined six months 
later, it was found that one institution had re- 

249 



NUTRITION AND GROWTH IN CHILDREN 

duced its percentage of malnutrition from 22 to 
less than 4 per cent, while in the other there 
had been practically no improvement. 

The explanation is that the latter institution 
had applied the program only in a general way, 
using it in so far as it did not interfere with 
the school schedule. In the other case the au- 
thorities believed that health is of more impor- 
tance than formal education, and, consequently, 
that education must be built upon health. They 
therefore bent all their energies toward the im- 
mediate end of bringing their charges up to 
average weight for height. 

It is interesting to note that this was accom- 
plished on an average daily food cost of 19 
cents per child, while the institution that made 
no progress was spending 40 cents a day ! 

Foster Homes. — In another institution de- 
voted to putting children in condition for plac- 
ing in foster homes an average of ^.ve physical 
defects per child was found after the children 
had been examined and reported up to the 
standard required for school and other activi- 
ties. Twenty per cent of these boys and girls 
averaged seven or more defects, and a group 
of 14 of those in the poorest physical condition 
was put under care in a nutrition class. The 

250 



INSTITUTIONS AND CAMPS 

defects were promptly corrected, and in 10 
weeks every child in the class was up to his 
normal weight line. 

Usually the children are placed in homes that 
do not receive full pay for the care taken, and 
they are sometimes required to share in house- 
hold tasks or chores beyond the limits of their 
strength. Most foster parents, however, have 
real interest in the children and can be depended 
upon to make sacrifices for them when neces- 
sary. 

In justice to this generous spirit on the part 
of foster mothers children should be made 
"free to gain" before they are sent out. 
They should be in condition to respond to good 
care, and not suffer from such handicaps as ob- 
structed breathing and other physical defects. 
Without this foresight there is always much 
illness, many visits from physicians are neces- 
sary, and additional care from specialists. 
This is discouraging for foster parents as well 
as for officers of child-placing institutions. 

Results that may be expected where chil- 
dren are first made "free to gain" are 
shown in the record of a nutrition camp 20 
miles out of the city, where more than 100 chil- 
dren from our nutrition classes were cared for 

251 



NUTRITION AND GROWTH IN CHILDREN 

with but one medical visit during a period of 16 
months, and this visit was required for a child 
who, by an oversight, was admitted to the home 
without being ' ' free to gain. ' ' 

The foster child *s health is his only capital, 
and everything possible should be done to save 
it from waste and impairment. The nutrition 
program provides a simple system for follow- 
ing progress by the report of his weight at reg- 
ular intervals, and for those who are under- 
weight the other features of the program can 
be applied without difficulty. 

Correctional Institutions. — All correctional 
institutions for children, such as truant and 
parental schools, should be so organized as 
to seize the first moment a child comes under 
their control to look into his physical condition. 
Much of the disciplinary difficulty with these 
children is due to bad physical condition, and 
surprising results in the way of improved be- 
havior frequently follow the removal of defects 
and improved nutrition. 

Summer Camps. — Another opportunity for 
complete control over the child's activities is 
afforded by the summer camp, which has the 
further advantage of reaching a wider range of 
children than those admitted to public institu- 
tions. Here, again, every child should be given 

252 



INSTITUTIONS AND CAMPS 

a complete physical examination and have his 
defects corrected before leaving home. This 
is the more important because camps are usually 
located at a distance from the large centers in 
which specialists are available, and, if a child 
becomes ill with such an affection as appendici- 
tis, or an acute middle ear with mastoiditis, an 
emergency operation may have to be performed 
under unfavorable conditions. 

All children at the camp should be weighed 
each day, and the programs of those who are 
underweight should be regulated by their 
weight charts. A boy who is far below normal 
weight should be absolutely forbidden to take 
severe physical exercise ; if only moderately be- 
low weight, he should have supervised exer- 
cise but no competition ; and unless fully up to 
weight, he should not be turned free to take 
long hikes or enter into exhausting contests. 

The temptations to overexertion are nowhere 
greater than in the camp, where even the new 
idea of the importance of health may lead a 
child to overtax his strength under the mis- 
taken notion that his gain will be in proportion 
to the energy expended. Under such conditions 
overfatigue may bring out some latent condition 
that will cause acute illness. Par too frequently 
children come back from a summer of misdi- 

253 



NUTRITION AND GROWTH IN CHILDREN 

rected camp life covered with medals but * ' thin 
as a rail." They are overtrained and on edge, 
with no margin of physical or nervous energy 
for the winter's work. 

The effect of the various forms of exercise 
upon the undernourished child should be care- 
fully observed. For example, each child should 
be inspected after a swim. If his reaction is 
not good, his time in the water should be short- 
ened, or it may be necessary to omit swimming 
until the weight chart, which is a sensitive indi- 
cator of the effect of all exercise, begins to 
show a good gain. 

Practically every part of the nutrition pro- 
gram is applicable to camp life. The progress 
indicated on the weight chart makes an excel- 
lent report to be sent each week to the parents, 
who will find in this record the best single index 
of the child's physical and mental condition. A 
boy who is really discontented or unhappy soon 
shows the effect in his weight line, whether the 
fault is in himself or in his surroundings. 

An important use of the camp has developed 
in the care of boys and girls who fail to come up 
to the physical standards required for employ- 
ment certificates or working papers. These 
camps are open all the year, and young people 
who are not physically fit for industry are here 

254 










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_ t- o 



INSTITUTIONS AND CAMPS 

brought up to weight before they are allowed 
to seek employment. After going to work they 
are still kept under observation, and if their 
employers cooperate, they seldom fail to con- 
tinue in good condition. 



CHAPTER XXV 

MALNUTRITION AND THE COMMUNITY 

Underdevelopment, undernourishment, and 
malnutrition are community problems that 
should be dealt with in the same spirit in which 
ignorance and disease are attacked. Normal 
physical and mental development are the best 
foundations for a wholesome national life. In 
spite of the success which may attend nutrition 
clinics and classes here and there, and the ex- 
cellent results secured with individual children 
in private practice, a nutrition program cannot 
be considered socially effective until every child 
is brought within its reach through the medium 
of a community-wide campaign. 

Training in health is one of the most natural 
and valuable means of education. Instead of 
resulting in self-consciousness, as is sometimes 
feared, it is the best way to avoid the dangers 
that come from prejudice, fear, and ignorance 
by teaching vital matters of health at an age 
when the habits formed have permanent effect 
on the development of the growing child. 

256 



MALNUTRITION AND THE COMMUNITY 

Nutrition Classes in the Schools. — A nutrition 
campaign therefore centers naturally in the 
public school. The school organization has ex- 
isting machinery through which to operate nu- 
trition classes, and these classes should form 
an integral part of its system so that every 
child may be reached. The person in charge of 
nutrition work should have the same authority 
in the schools that the medical inspector has in 
the case of tuberculosis or other illness. 

In addition to classes in the schools several 
cities have already established nutrition camps 
for children who fail to pass the physical ex- 
amination for employment certificates. Work- 
ing papers are withheld until the children are 
brought up to normal weight, and when they 
are considered ready to enter industry, their 
needs are explained to the employer so that 
proper adjustments may be made to keep them 
in good condition. 

The fundamental preventive work of the nu- 
trition class underlies the problem of the asso- 
ciated charities, the hospital, the church, the 
juvenile court, and, in fact, all child-helping 
organizations. Each of these agencies can as- 
sist in carrying out essential features of the nu- 
trition program, and will find its own burden 
lessened by close cooperation on a unified plan. 

257 



NUTRITION AND GROWTH IN CHILDREN 

By discovering and removing the causes of 
many diseases, and giving health instruction to 
groups in schools, the nutrition class greatly 
reduces the number of children who need to 
apply to hospitals for treatment. Most of 
the out-patient work with children has to be 
done on Saturday morning, and the busy phy- 
sician now has to take time for individual ad- 
vice on general matters of health that should 
properly be devoted to careful diagnosis. In 
other words, the out-patient department should 
be a diagnostic clinic, and not a combination of 
medical and welfare work with health instruc- 
tion. 

Nutrition Clinics for Problem Cases. — The 
distinction between the nutrition class and the 
nutrition clinic should be kept in mind. In 
nearly every group there will be problem cases 
not solved by the routine examination and class 
procedure. Obscure symptoms require long 
observation before their true character is un- 
derstood. To take care of these cases there 
should be a nutrition, or diagnostic, clinic in 
every county, in each of the smaller cities, and 
at every hospital in the larger centers, where 
all the resources of these institutions can be 
brought into service when needed. 

All of the specialized departments for cor- 
258 



MALNUTRITION AND THE COMMUNITY 

rective work should be available, but the most 
important is adequate provision for the removal 
of diseased adenoids and tonsils. Even in our 
best equipped cities children are scheduled 
months ahead for such operations, and when a 
nutrition ? lc >ss is organized it often happens 
that the greater part of the first year is gone 
before it has been possible to secure corrective 
treatment for all the children in need of care. 

The city of Rochester, New York, has enlisted 
the interest of the association of allied hospitals 
in this work in cooperation with the schools and 
all other child-helping organizations. Special 
facilities have been provided to care for more 
than 100 children at a time so that all may have 
adequate rest in bed following the operation. 
The Rotary Club and other social organizations 
helped, and the press kept parents and friends 
so well informed concerning what was taking 
place that the common prejudice against going 
to a hospital was overcome, and children were 
eager for their turn. There were over 1,700 
operations on diseased adenoids and tonsils 
during the first month, and 13,372 operations 
have been performed with no casualties. 

The funds for this work came from a "com- 
munity chest," which effectually prevented the 
usual overlapping of boundaries between asso- 

259 



NUTRITION AND GROWTH IN CHILDREN 



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FlGUBE 39. CONTINFED GAIN AFTEB ENTERING INDUSTBY 

Frank M. was refused a working certificate, and sent to the Arden 
Shore Camp of the Elizabeth McCorrnick Memorial Fund, Chicago. 
Follow-up work secured the cooperation of his employer, and he 
was provided with a glass of milk in the middle of the morning and 
the middle of the afternoon. His chart shows a gain of 11 pounds 
in three weeks after he went to work. 

ciations, and the consequent waste of money, 
time, and energy. 

Extension Service. — Each state or county 
should also have an organized extension service 

260 



MALNUTRITION AND THE COMMUNITY 

by moans of which diagnostic and operating 
clinics may bo carried to communities distant 
from the larger centers. By the use of trucks 
and tents all the essentials of clinic service can 
be made available for every child and the neces- 
sary operations performed without undue risk 
or danger. These extension facilities are also 
valuable for carrying health instruction into 
outlying communities. 

Nutrition rallies afford an excellent means of 
getting into direct contact with the parents, and 
of bringing their responsibilities home to them. 
The speakers need not necessarily be acquainted 
with the technique of nutrition work. In every 
community there are men and women of ability 
who have broken down through failure to recog- 
nize the essentials of health. Many of these 
have worked their way back to good health, and 
the road by which they have made recovery is 
a matter of interest to others. 

The nutrition program is not a matter of con- 
cern in regard to children alone. Parents, 
teachers, and other adults are finding in it the 
way to health for themselves. A thorough- 
going health program will include health oppor- 
tunity and education for all ages. The out-of- 
door contacts of the Boy and Girl Scouts should 
be so extended in scope as to arouse the interest 

261 



NUTRITION AND GROWTH IN CHILDREN 

of all the members of the family. A program 
of this kind will also relate itself naturally to 
the provision of health classes for adults in 
evening schools, and of community outing clubs, 
camping grounds, golf courses, and all other 
means of making it easier for every one to se- 
cure the requisites for good health. 

Outline of a Community Program. — In order 
to make a community campaign effective, ade- 
quate preparation is necessary, and the follow- 
ing steps are suggested for the formation of one 
complete nutrition unit : 

First. — A local committee should be organ- 
ized, representing the following interests : 

1. A progressive physician who knows the existing 
medical agencies 

2. A prominent member of a child-helping organ- 
ization having access to all branches of estab- 
lished welfare work, who will secure unity of 
purpose and cooperation among social workers. 

3. A school principal or teacher who appreciates 
that education in health should be made an 
integral part of the school system 

4. An editor or publicity man who knows how to 
reach, inform, educate, and use all social groups 

5. A banker or business man who can organize 
finances, records, etc. 

6. A socially prominent person who can arouse the 
interest of influential members of the com- 
munity. 

262 



MALNUTRITION 1 AND THE COMMUNITY 

Second. — The services of a well-trained nu- 
trition worker should be engaged to organize 
and manage the classes. A physician thor- 
oughly interested in the work should be secured, 
to be responsible for the medical diagnoses, for 
making the physical examinations, and to aid in 
conducting the weekly meetings of the classes. 

Third. — All supplies and equipment that will 
be needed should be secured, including scales, 
record forms, and literature. 1 

Fourth.— A place should be provided where 
the classes may meet regularly. There should 
be a room for the physical examinations, and 
space in which the nutrition worker may keep 
her records and supplies. Plans should be made 
for the execution of the essential features of the 
program, such as the place and time for rest 
periods and lunches ; conferences with parents ; 
visits to homes; cooperation with the school 
principal, teachers, nurses, and physicians. 

Fifth. — The children in one school, or at least 
a group of 300, should be weighed and meas- 
ured. Among this number there will be from 
60 to 100 who are at least seven per cent under- 
weight for their height and in need of treat- 
ment. One nutrition worker w T ill be able to care 



1 See List of Publications, p. 331. 
263 



NUTRITION AND GROWTH IN CHILDREN 

for about 100 children, and five classes should 
be formed from this number. 

Sixth. — The movement should be advertised 
by ample publicity. Poster competitions and 
other contests in the schools will interest the 
children. Speakers on the programs of local 
and state meetings of educational, social, med- 
ical, and labor organizations, and articles in all 
the local papers, will help to arouse the public. 
The committee should keep in touch with the 
women's clubs, parent-teacher associations, and 
similar organizations. The public library 
should be asked to supply books and periodicals 
on nutrition, and to feature them on its bul- 
letin board. 

Seventh. — Records should be carefully kept. 
The various forms and blanks printed in 
the appendix are the result of long experience, 
and should be thoroughly understood. These 
records are important, not only to show what is 
accomplished locally, but as data that may aid 
in extending the scope of the work and help in 
solving difficult problems elsewhere. 

Eighth. — The main purpose should be kept in 
mind. The committee should keep in touch 
with all indications of interest in community 
health; secure exact knowledge about medical 
inspection in the schools and the examination 

264 



MALNUTRITION AND THE COMMUNITY 

of candidates for working papers; follow up 
plans for summer outings, aids for convales- 
cents and for cases of special need; keep posted 
on the teaching of hygiene, food values, physical 
training, etc. Nevertheless, all these things 
must be considered in relation to the central 
purpose for which the nutrition unit has been 
organized, that of health education and of re- 
storing malnourished children to normal stand- 
ards of growth. 



CHAPTER XXVI 

MALNUTRITION AND TUBERCULOSIS 

The problem of tuberculosis is the problem 
of nutrition. Malnutrition in children usually 
illustrates either failure or neglect on the part 
of the physician: failure, because the condi- 
tion is rarely diagnosed; neglect, because he 
does not take time to get at the real condition 
and its causes. The fact that it has not been 
recognized as a medical diagnosis makes the 
malnourished child an easy prey to tuberculosis 
and other diseases. An undernourished body 
is the best possible culture ground for tubercle 
bacilli. 

Malnutrition is common among families in 
which tuberculosis is present, but instead of 
giving the malnourished child special care be- 
cause of his lowered resistance, the physician's 
attention is frequently so fixed upon the tu- 
bercular process itself that he takes little heed 
of the child's actual condition in other respects. 
Furthermore, the nurses in charge of such fami- 
lies have been trained in the care of bed pa- 
tients, and seldom understand what to do for 

266 



MALNUTRITION AND TUBERCULOSIS 

these children until they are so ill as to be 
beyond help. 

The five chief causes of malnutrition are 
strikingly evident in families suffering from 
tuberculosis. Uncorrected physical defects are 
more frequently found here than elsewhere. 
In one large group of such children in Boston, 
50 per cent were in urgent need of operations 
to remove diseased adenoids and tonsils, after 
having been under treatment, in some cases for 
years, in a tuberculosis clinic. 

The second of these causes is lack of home 
control, and in no other group have we found 
so many seriously disorganized homes. In long 
illness the mother's care is concentrated upon 
the sick person, and her attention is diverted 
from the other members of the family, which 
tends to break up those habits of regularity and 
order upon which successful home life depends. 
When the sick member is taken away for treat- 
ment, the family is sometimes broken up tem- 
porarily, and when the mother gets her little 
flock together once more the old unity is gone, 
and it is difficult to reestablish the influence of 
family habits and customs. 

It is better policy wherever possible to keep 
the family together and to take care of the pa- 
tient at home. It should be recognized that only 

267 



NUTRITION AND GROWTH IN CHILDREN 

in pulmonary tuberculosis is there serious dan- 
ger of communication of the disease, and the 
treatment prescribed for the victim of tubercu- 
losis is also desirable for those who are well. 
Open air, ample nourishment and rest, as ad- 
vised for the tuberculosis patient, will increase 
the resistance of the other members of the fam- 
ily. When a cure is effected in the patient's 
own home, new habits are established that tend 
to make the results permanent. 

Overfatigue is a constant factor in tubercu- 
losis. In one of our classes there was a girl of 
14 who had spent some time in a tuberculosis 
sanitarium. She was one of 9 children, and was 
found by the nutrition worker to be doing most 
of the housework, including the washing. As 
an older sister required the only good room for 
callers in the evening, this girl and a younger 
sister, also an incipient case, had to sleep in a 
small dingy room on a court. The family had 
pie for breakfast, and tea or coffee at every 
meal. The mother seemed thoroughly indiffer- 
ent; all the children suffered from pediculosis. 

This girl was five grades behind her age in 
school, and her teacher applied all possible 
force to hold her up to the requirements. This 
involved staying after school, home work under 
unfavorable conditions, and when she was un- 

268 



MALNUTRITION AND TUBERCULOSIS 

able to keep up even under this pressure, she 
was sentenced to a term at the summer session 
of the vacation school. As it was impossible to 
persuade the school authorities to give her a 
reduced schedule, she had to be taken out of 
school entirely and sent to the country to re- 
cuperate. Here she was free from overfatigue, 
and gained seven pounds in four weeks. Dur- 
ing her absence the mother's pride was awak- 
ened, and the home organization changed so 
that it soon ranked the best among 50 families 
then under observation. In 30 weeks on the 
nutrition program this child gained 435 per- 
cent of the expected rate of gain in weight for 
her age. 

Another girl in the same nutrition class had 
more favorable home conditions, but was under 
constant strain because her brightness and at- 
tractiveness led to exploitation by school and 
social agencies. She was the leading figure in 
all school plays, attended club meetings at 
neighboring settlements four days each week, 
had a piano lesson on Saturday morning, and, 
as chief entertainer, danced frequently at wed- 
dings in the homes of friends and neighbors. 
When her mother was made to understand the 
meaning of this overfatigue, which made the 
child "too tired to eat," and was rendering her 

269 



NUTRITION AND GROWTH IN CHILDREN 

specially susceptible to tuberculosis, her whole 
program was changed, and she was soon up to 
normal weight. 

Fifty per cent of this class, which was com- 
posed of children who were suspected of being 
tuberculous or had been directly exposed to 
tuberculosis — were doing extra tasks outside of 
school hours. There were music and language 
lessons, club meetings, and various forms of 
" gainful occupation." Sixty-four per cent 
kept late hours. Much of this was easily cor- 
rected, but there were too many cases like that 
of a girl of eleven, 15 per cent underweight and 
very delicate, who was studying every night 
until after 11 o'clock — on the waiting list of a 
sanitarium, yet compelled to carry out a school 
program too heavy for even a well child ! 

The next cause of malnutrition enumerated — 
improper diet with faulty food habits — is also 
of special importance in tuberculosis. The ab- 
normal conditions of long illness lead to irregu- 
larity in eating and a disregard of fundamental 
requirements. Attention is often so completely 
focused upon supplying the food needs of the 
sick person that the other members of the fam- 
ily are neglected. In the group studied 28 per 
cent were not taking sufficient food, not because 
there was not enough available but because of 

270 



MALNUTRITION AND TUBERCULOSIS 

faulty food habits. Thirty-six per cent were 
habitually fast eaters. 

The fifth cause of malnutrition — faulty health 
habits — is bound up with the others already dis- 
cussed. In the class above mentioned, funda- 
mental health needs were overlooked even 
where children were under treatment, and the 
families given aid. Exercise and play in the 
open air and sunlight had a very small part in 
these children's lives, and they were allowed to 
sleep under conditions that destroyed the good 
effect of all the help given. 

The care of these so-called "pre-tubercular" 
children should be part of a " Physically Fit" 
campaign in which all organizations interested 
in children should be brought into association. 
When the attempts to aid these families are cen- 
tered in a specially labeled tuberculosis clinic, 
the children suffer from the stigma of being 
called "pip" cases by their companions. 

Public money should no longer be spent 
with one hand to make well children sick and 
sick children worse through overfatigue at 
school, while the other makes appropriations 
for sanitaria to make them well. Every child 
applying for entrance to the public school 
should be examined in the presence of his par- 
ents and required to be up to normal weight 

271 



NUTRITION AND GROWTH IN CHILDREN 

before he is allowed to assume the burden of 
full school work. Settlements and other social 
organizations, while continuing the good work 
they are doing, should not leave undone the duty 
to see that the children are in condition to profit 
by what is offered them. Health crusades 
should not give highest honors to athletic 
achievement without knowing whether it is rest 
or activity that is most needed for proper devel- 
opment in each individual case. Boy and Girl 
Scouts should put the emphasis on growth and 
health by requiring as a first step in the prog- 
ress of the "tenderfoot" that he have a body 
weight sufficient to sustain his height. The 
elimination of malnutrition from any com- 
munity is its greatest safeguard against tu- 
berculosis. 




CHAPTER XXVII 

MALNUTRITION AND PREVENTIVE MEDICINE 

No branch of medical science promises so 
much for the future as preventive medicine. 
Dramatic operative procedure, intravenous and 
intraspinal medication mark wonderful ad- 
vances in saving life, but how much farther we 
shall have progressed when the need for such 
extreme measures has been prevented as far as 
possible. 

More than one-half of the diseases of child- 
hood, including meningitis and scarlet fever, 
ire preventable, and the length of human life 
could be increased one-third were the existing 
knowledge of hygiene universally applied. 1 It 
is estimated that at least one-half of the 3,000,- 
000 or more sick beds constantly filled in the 
United States would be unnecessary, and over 
600,000 yearly deaths might be prevented, if 
such preventive measures as are entirely practi- 
cable were promptly undertaken. The annual 

1 Irving Fisher, "Economic Aspects of Lengthening Hu- 
man Life." 

273 



NUTRITION AND GROWTH IN CHILDREN 

loss in earnings cut off by these preventable 
diseases and premature deaths reaches the 
stupendous sum of $1,500,000,000. 2 

Such estimates do not consider the lowered 
efficiency of countless other persons who go 
through life in a state of partial invalidism — 
those who never know what it is to be really 
well. 

The Nutrition Program and Prevention. — The 
first step in prevention is to establish good nu- 
trition and health in the infant, which is at once 
reflected in lowered mortality rates. Milk sta- 
tions in our crowded cities have demonstrated 
that one nurse can safely carry 75 to 100 babies 
through a hot summer, not only keeping them 
free from serious illness but actually gaining in 
weight, by intelligent supervision and weekly 
weighings. 

If the same supervision and care, with 
monthly weighings, were carried through the 
entire period of growth, it requires little im- 
agination to see what an immense saving of 
time and expense would result, as well as the 
prevention of most of the diseases and deformi- 
ties treated at the hospitals. This is what we 
propose in our nutrition program, utilizing the 



2 Fisher and Fisk, "How to Live." 
274 



PREVENTIVE MEDICINE 

school organization that all children may be 
reached. 

One of the first indications of disease is loss 
of weight, and it is in the underweight group 
that most cases of serious illness arise. Just as 
the malnourished child, because of his low re- 
sistance, falls an easy prey to tuberculosis, so 
also he readily succumbs to other infections. 
It has been demonstrated in our classes repeat- 
edly that when a child who is severely under- 
weight contracts an illness, as during a mild 
epidemic of scarlet fever, he falls a victim to 
the disease almost without a struggle. 

In one instance, the mother of a bright and 
precocious boy was unwilling to have him omit 
violin lessons, which, in addition to his school 
work, were clearly causing overfatigue. Two 
weeks later the boy succumbed to an acute ill- 
ness, and the mother returned to the clinic to 
inquire pathetically if we thought her boy 
would have lived if his violin lessons had been 
stopped. 

The mere weighing and measuring of a group 
of children marks an initial step in the preven- 
tion of disease. In one community the under- 
weight children showed in 10 weeks' time 61 per 
cent more than the average gain of well chil- 
dren, following no other application of the nu- 

275 



NUTRITION AND GROWTH IN 1 CHILDREN 

trition program beyond the weighing and meas- 
uring. 

The fact that so many children are found to 
be below the average weight for their height 
should be a challenge to all the forces concerned 
in safeguarding their health. In the nutrition 
program the complete physical-growth exami- 
nation, following immediately after the weigh- 
ing and measuring, is an important step in pre- 
vention by disclosing the causes of the child's 
malnutrition. The early removal of these 
causes saves immeasurable suffering and loss of 
life. 

How much better it is, for example, to re- 
move infected tonsils before the inflammatory 
process has left permanent marks upon the 
child's development, or led to complications 
arising from the spread of the infection to vital 
organs of the body. The diagram on page 277 
illustrates how the early discovery and removal 
of the causes of malnutrition may prevent re- 
sults that are taxing to the utmost our hospitals 
and other institutions. 

Effect of Wrong Ideas. — It would be inter- 
esting if we were able to measure the effect of 
wrong ideas upon the health of the community. 
A fear of disease arising from the manifesta- 
tion of normal processes has an effect upon the 

276 



PREVENTIVE MEDICINE 



Common Defects and Results of Neglect 



Early Diagnosis and Preven- 
tive Work in Nutrition 
Classes in the School 



Naso-pharyngeal obstruction " 



Postural defects 



Eye strain 



Teeth defects 



Poor hygiene, etc. 
Tea and coffee habits 



Early appendicitis 



Malnutrition 



{ 



{ 



Late Diagnosis and Corrective 
Work in Out-patient Depart- 
ments and Hospital Wards 

Otitis media 

Deafness 

Mastoiditis 

Sinus infection 

Cardiac disease 

Joint infections 

Nephritis 

Pyelitis 

Asthma 

Emphysema 

Fatigue posture 

Flat foot 

Spinal curvature 

Round shoulders 

Visceroptosis 

Impaired vision 

Headache 

Fatigue 

Carious teeth 

Antrum infection 

Alveolar abscess 

Malocclusion 
__ Deformities of face and jaw 

Anemia 

Acne 

Eczema 

Pediculosis 

Intestinal parasites 

Gastritis and intestinal indiges- 
tion 

Disturbance of the nervous sys- 
tem 

Fulminating appendicitis 

Peritonitis 

Intestinal adhesions 

Tuberculosis 

Syphilis 

Lowered resistance to infection 

Postural defects 

Early senility 

Impaired race 



277 



NUTRITION AND GROWTH IN CHILDREN 

whole after life of the individual. A mistaken 
impression about drafts or night air may lead to 
faulty health habits with serious consequences. 
An early prejudice against resting in the day- 
time is often responsible for overfatigue, which 
leads in time to a totally unnecessary break- 
down. A wrong idea of some particular rela- 
tion of cause and effect may lead one to put his 
trust in some nostrum, superstition, or cult. 

Many erroneous notions on the part of both 
parents and children come out in the class meet- 
ing and in other phases of the nutrition pro- 
gram. For example, one mother was omitting 
cereal from a child's diet in the summer be- 
cause she thought oatmeal was heating ; another 
tried to build up her undernourished child on 
beef tea, which she thought particularly nour- 
ishing; a boy who was seriously underweight 
was trying to keep his weight down by under- 
feeding because he thought if he became fat he 
could never be an athlete; another boy failed 
to eat sufficient food for fear of appendicitis; 
another stayed up late at night because he 
thought there was no need to go to bed unless 
he could fall asleep immediately. 

During the campaign to secure money for the 
suffering children in Europe, the principal of 
a high school in a large city proposed to the 

278 



PREVENTIVE MEDICINE 

pupils that they go without lunches every other 
day and put the money into the relief fund. 
This unwise proposition was accepted with en- 
thusiasm by the pupils and applauded by the 
newspapers throughout the country because no 
one seemed to appreciate the anomaly of under- 
feeding growing children here in order to re- 
lieve the distress resulting from the same cause 
abroad. 

Health Education and Prevention. — Preven- 
tive medicine should include such instruction as 
will eradicate these false ideas before they be- 
come fixed, and bring matters pertaining to 
health clearly over into the regions controlled 
by sound experience and common sense. The 
surest safeguard against these unreasonable yet 
powerful influences is a fund of knowledge con- 
cerning the essentials of growth and health. 

Discriminating consideration for one's own 
physical condition leads away from morbid self- 
analysis. It is the person lacking the essential 
knowledge and the trained executive ability to 
keep himself fit who falls a victim to hypo- 
chondriacal ideas. It is important to use every 
means of discovering such insidious ideas and 
overcoming the habits that grow out of them. 

In the prevention of sickness we have an op- 
portunity for health education of the highest 

279 



NUTRITION AND GROWTH IN CHILDREN 

order. A child should be as thoroughly drilled 
in the essentials of health as in the principles of 
arithmetic or language. 

Infection is an invasion of organisms which 
threaten life, and must be met by leucocytes 
from the blood. A battle is fought between 
them as real as that of armies, and the stronger 
wins. Preparedness is more necessary in the 
life of the child than in that of the nation, be- 
cause, while the occasion for actual warfare 
may not arise, there is no escape from the 
child's risk of infection from the destructive 
organisms, which are constantly present as 
though waiting for a favorable opportunity to 
attack. 

Davidsohn reports 3 that in Berlin there was 
a marked increase of tuberculosis infection in 
children during the war, 48 deaths per 10,000 
of the population occurring in 1919, as com- 
pared with 32 in the year before the war. The 
European epidemics which caused a high mor- 
tality during this period also show a distinct 
relationship between malnutrition and the 
prevalence of infection. 

The best insurance that a child has against 

3 H. Davidsohn, "Die Wirkung der Aushimgerung 
Deutschlands auf die Berliner Kinder," Zeitschrift fur 
Kinderkrankheiten, 21 : 349, 1919. 

280 



PREVENTIVE MEDICINE 

sickness is not necessarily the most healthful 
surroundings, but a sound body to resist dis- 
ease. Ideal surroundings are not always avail- 
able for every child, but our nutrition classes 
have shown that it is possible to establish a 
sound body in almost any environment. Health 
once established in the growing period by 
health education will, as a rule, continue 
throughout life. Health and education should 
go hand in hand — health in education and edu- 
cation in health. 



CHAPTER XXVIII 

THE EXTENT OF MALNUTRITION AND SOME RESULTS OF 
NUTRITION WORK 

The most reliable evidence of the extent of 
malnutrition is secured by weighing and meas- 
uring groups of children in various localities 
representing family circumstances of wide va- 
riety. In this chapter statistics are presented 
in Table VII that answer the questions so often 
asked, "How much malnutrition is found in 
representative American communities ? ' ' and 
"Is not malnutrition largely confined to the 
poor?" 

Since the best record of progress in regain- 
ing health appears in the weight chart, we are 
also giving figures in Table VIII that show the 
gains made in similarly varied communities 
where our nutrition program has been carried 
out. 

We have collected a large amount of data 
which have been secured by schools, medical au- 
thorities, and others with reference to the ex- 
tent of malnutrition in Europe and America, 
but because of the lack of a single objective 

282 



EXTENT OP MALNUTRITION 

standard on the part of the examiners, the wide 
range of individual differences makes the 
greater part of this material of little value for 
purposes of comparison. Thousands of chil- 
dren have been weighed and measured, how- 
ever, during the last few years according to the 
methods outlined in this book, and the record 
thus secured may be taken as reliable evidence 
of the prevalence of malnutrition in this coun- 
try. These figures are given in Table VII on 
the following pages. 

It will be observed that these statistics have 
been gathered in a territory ranging from At- 
lanta to Boston, New York, and Chicago in the 
United States, and extending into Canada and 
Labrador in the British possessions. The out- 
standing facts in the table are the wide extent 
of malnutrition in all sections entered and its 
striking prevalence in all classes of society. 
Wherever comparison has been made, it has 
been found that the proportion among the so- 
called "better classes" is as great or even 
greater than among the poorer and immigrant 
groups. 

In the early stages of our work with mal- 
nourished children we gave them the best pos- 
sible care according to our knowledge at 
that time, increasing the amount of food, im- 

283 



NUTRITION AND GROWTH IN CHILDREN 
Table VII. Extent of Malnutrition 




• Whenever small groups are given, they represent the entire 
membership of certain elasses. and in no case have the figures been 
Influenced by special selection. s 

284 



EXTENT OP MALNUTRITION 
Table VIT. Extent of Malnutrition — Continued 





Number of 
Cases 


Percentage of Malnutrition 


Locality 


Borderline 
Under- 
weight 
less than 7 
Per Cent 


Under- 
weight 
7 Per 
Cent or 

More 


Under- 
weight 
10 Per 
Cent or 
More 


Dayton, Ohio : 
Public school 


246 

312 

360 
202 

492 

251 
76 
61 

104 

894 
255 
127 
245 
173 
25 

69 
401 




40 

21 
21 
36 

25 

32 
21 
23 
13 

18 
17 
21 
16 
14 
28 

28 

26 
23 
36 

42 
34 
60 
37 
29 

28 
58 
54 
29 




Illinois: 
School for Soldiers' 


19 
19 
24 




School for Deaf 




School for Blind 




Manchester, N. EL : 
Total survey : 
Three "better class" 
schools 








Greek group 

Polish group 

French-Canadian group 

New York City : 

Public School 64 (East 
Side) 












Grade I 

Grade V 

Grade VI 

Grade VII 

Open air class .... 

Specials ("exception- 
ally bright") 

Rochester. N. Y. : 

Public schools 

Immigrant poor group 
































St. Anthony, Labrador : 
Total survey : 


191 
41 
63 
52 
35 

241 

714 
670 

882 








Village ............. 










Bight 




Toronto. Canada : 

York School (Russians. 
Poles, Italians, Chi- 
nese. Japanese) .... 

Dufferin School 

Withrow School 

Brown School 




14 




35 




34 
14 







285 



NUTRITION AND GROWTH IN CHILDREN 
Table VII. Extent of Malnutrition — Continued 





Number of 
Cases 


Percentage of Malnutrition 


Locality 


Borderline 
Under- 
weight 
less than 7 
Per Cent 


Under- 
weight 
7 Per 
Cent or 
More 


Under- 
weight 
10 Per 
Cent or 
More 


Walpole, Mass. : t 

Public schools 


1,305 


19 
15 

22 
21 
22 
19 
22 
20 
22 
18 
11 
10 
20 
6 

22 
20 
20 

10 
14 
12 

20 
18 
19 


36 
30 
37 
35 
40 
37 
44 
43 
35 
43 
25 
29 
15 
29 

34 
43 
39 

25 
23 
24 

33 
39 
36 






Grade I 






Grade II 






Grade III 






Grade IV . 






Grade V 






Grade VI 






Grade VII 






Grade VIII 






Grade IX 






Grade X 






Grade XI 






Grade XII 






Elementary grades 
Boys 






Girls 






Both sexes 






High School: 

Bovs 






Girls 






Both sexes 






All grades : 

Boys 






Girls 






Both sexes 













t distribution op malnutrition in walpole according to 
Percentage Underweight 



Underweight 


Cases 


Underweight 


Cases 


Per Cent 


Per Cent 


Per Cent 


Per Cent 


1 


.8 


12 


2.6 


2 


1.3 


13 


2.2 


3 


3.4 


14 


1.4 


4 


4 


15 


1.5 


5 


4.5 


16 


.6 


6 


5 


17 


1.2 


7 


5.3 


18 


.6 


8 


5.5 


19 


.6 


9 


4 


20 


.8 


10 


6.1 


21 





11 


3.3 


22 


.3 



286 



EXTENT OF MALNUTRITION 
Table VII. Extent of Malnutrition— Continued 





Number of 
Cases 


Percentage of Malnutrition 


Locality 


Under- 
weight 
Borderline 
less than 7 
Per Cent 


Under- 
weight 

7 Per 
Cent or 

More 


Under- 
weight 
10 Per 
Cent or 
More 


Washington, D. C. : 
Total survey 


3,913 






29.5 


White 






36 


Colored 








26.3 


Kindergarten 








22.7 


Grade I 








28.8 


Grade II 








24.8 


Grade III 








27.9 


Grade IV 








25.8 


Grade V 








30.7 


Grade VI 








33.9 


Grade VII 








33.7 


Grade VIII . 








34.3 


Williamstown, Mass. : 


443 
240 
203 






30.6 


Boys 5 to 14 years. 






26.6 


Girls 5 to 15 






35 











proving the sleeping conditions, and correcting 
other matters of general hygiene. The result 
was that the few children who needed only these 
simple adjustments came up to normal weight 
promptly, but the majority persisted in making 
either very slight gains or none at all. The 
chart given in Figure 40 reports a typical case 
of this period. 

Despite such convincing records, efforts are 
still made to do away with malnutrition by giv- 
ing attention principally to a single factor such 
as diet. Figure 41 gives the recently published 



287 



NUTRITION AND GROWTH IN CHILDREN 

results 1 of classes conducted under the most 
modern principles of dietary efficiency as com- 



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Figure 40. an early chart; no gain 

This is one of our early charts showing an entire lack of progress 
during a period of 20 weeks. While this boy was under observa- 
tion, all possible causes for his underweight that were known at 
that time were removed. Treatment was continued for 20 weeks 
more with no relative gain. The cause was overfatigue, the sig- 
nificance of which was not then recognized. Average weight for 
age was the standard in use at that time, and as this boy belonged 
naturally to the group under the average size, it was practically 
impossible for him to attain the average weight 
for his age. 

pared with the record of one of our nutrition 
classes. 



1 See footnote, p. 191. 



288 



EXTENT OF MALNUTRITION 

Contrast the outcome of these limited pro- 
grams with the results that have followed a 
careful use of the procedure outlined in this 
book. Figure 42 shows what may be expected 



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FlOUBE 41. NUTRITION CLASS AND DIET CLASSES COMPARED 

This chart illustrates the gains made in two classes conducted with 

special emphasis on dietary standards, compared with the results 

accomplished in a nutrition class under similar social conditions, 

where attention was given to all the essentials 

of health. 



in a nutrition class carried on under ordinary 
circumstances with good cooperation of the par- 
ents. Figure 43 reveals the still higher results 
obtained in a private school which adds to the 
usual good conditions the potent and significant 
factor of a sane school program where health is 
considered as a matter of fundamental impor- 

289 



NUTRITION AND GROWTH IN CHILDREN 

tance, essential to education and in no way an- 
tagonistic to it. Figure 44 registers results re- 
cently secured in a class of " contact' ' cases 
(children who had been exposed to tubercu- 



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FlGUBE 42. A 1918 CLASS AT THE BERKELEY INFIBMABY, 
BOSTON 

Half a dozen nationalities were represented in this group, as well 

as a wide variety of family circumstances. The causes of their 

malnutrition were equally varied, but all came up to normal weight, 

making more than five times the average rate of gain. 

(Mabel Skilton, nutrition worker.) 



losis), in a nutrition camp which was under 
full control of the nutrition worker 24 hours 
a day. 

Table VIII shows what has been accom- 
plished in representative classes working on our 
nutrition program. This plan has proved ef- 

290 



EXTENT OF MALNUTRITION 

ficacious in removing malnutrition in a wide 
range of situations, including children in the 



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FlGUBE 43. CLASSES IN THE FRANCIS W. PARKER SCHOOL, 
CHICAGO, 1920 

In this school nutrition work has the hearty cooperation of princi- 
pal and teachers, with the result that five nutrition classes, con- 
taining 70 of the most seriously underweight children, made an 
average gain of 559 per cent during the first seven weeks of class 
treatment. (Elizabeth McCormick Memorial Fund, 
Marion Moseley, nutrition worker.) 



homes of wealthy and poor alike, in public, 
parochial, and private schools, orphan asylums, 

291 



NUTRITION AND GROWTH IN CHILDREN 



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Figure 44. 



GROUP GAIN AT A NUTRITION CAMP IN GRAND 
RAPIDS, MICHIGAN, 1920-21 



This chart shows a remarkable sain of 1.400 per cent for 28 chil- 
dren of school age. Our nutrition program has been strictly fol- 
lowed, with special reference to the prevention of overfatigue, 
although a considerable number of the children attended school all 
day. The camp was maintained for the first two months of 1921 at 
a food cost of 35 cents per day per child, and the total cost has not 
exceeded $7.12 per capita per week. This is not a chronological 
chart, but a composite of the gains of the actual first, second, third, 
and fourth weeks, etc., of the various members of the group, show- 
ing the more rapid rate of gain during tbe early weckSj tapering 
off as the children approached normal weight. (Tuberculosis 
Association, Enid Bailey, nutrition worker.) 



summer camps, hospital out-patient depart- 
ments, social settlements, and in child-helping 
organizations of all kinds. 

292 



EXTENT OF MALNUTRITION 



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EXTENT OF MALNUTRITION 

Two groups listed under Boston well illus- 
trate the difference in the results secured when 
there is reasonable cooperation and when this 
cooperation is lacking. These are the Berkeley 
Infirmary and the Tuberculosis groups, where 
the classes were conducted under similar con- 
ditions in buildings a few blocks apart. 

The children in the Tuberculosis classes came 
largely from a district that is known as one of 
the most congested areas in the world. In spite 
of the evident need to safeguard their health 
in every possible way, whenever the demands 
of health and school appeared to conflict, the 
school authorities decided to enforce the latter. 
They objected to absence on account of dental 
work or adenoid and tonsil operations, and were 
unwilling to modify the school program suf- 
ficiently to allow the children time for the rest 
periods which they required. 

The Infirmary class, on the other hand, was 
made up of children who came from outside 
districts in which the schools were ready to co- 
operate, with the result that where the one 
group made only 205 per cent of the expected 
rate of gain, the other progressed at the rate of 
525 per cent. 

The remarkable gains appearing in groups 
under institutional management are explained 

300 



NUTRITION AND GROWTH IN CHILDREN 

by the regularity of their daily program and 
freedom from the interruptions, excitement, 
and nervous stimulation of the average house- 
hold. When the importance of home control is 
fully recognized, these results can be achieved 
in the home, where, under proper organization, 
even more favorable conditions for growth and 
development should be attainable. 

The highest individual rates of gain recorded 
were found to be closely associated with a previ- 
ous condition of serious underweight. 

While these boys and girls have been getting 
well, they have also been receiving health edu- 
cation which tends to make their recovery 
permanent. These results have been brought 
about for the most part without taking children 
out of their own environment or making ex- 
traordinary changes in their daily programs, 
and without adding to the expense for food. In 
cases wherein extra milk was required, it has 
usually been possible to offset this by a saving 
in some other item of the household budget. 

A study of the results accomplished in scores 
of classes makes it clear that any group work- 
ing on our nutrition program should make a 
gain of at least 200 per cent of the normal ex- 
pectation. The work has not been carried on 
where conditions were specially favorable for 

301 



EXTENT OP MALNUTRITION 

securing high rates of gain, but, on the con- 
trary, in what would be considered the most un- 
favorable localities, such as the West and South 
Ends of Boston, the East Side of New York, 
and the stockyard district of Chicago. It is 
therefore a demonstration that with proper care 
and intelligent planning malnutrition can be 
eliminated from any community. 



APPENDICES 



APPENDIX I 

TABLES OF WEIGHTS 
Table I. — Average Weights of Ciiildbkn at Various HneKTfl 



BOYS 


<;jkls 




Average 


7 


10 


Average 


7 


10 




neight, 
Inches 


Weight 
for 


per cent 
Under- 


per cent 
Under- 


Weight 
for 


per cent 
Under- 


per cent 
Under 


Height, 
inches 


Height, 


weight. 


weight, 


B eight 


weight, 


weight. 




pounds 


pounds 


pounds 


pounds 


pounds 


pounds 




•21 


8.2 


7.6 


7.4 


7.9 


7.3 


7.1 


21* 


•22 


9.7 


9.0 


8.7 


9.4 


8.7 


8.5 


22* 


•23 


11.1 


10.3 


10.0 


11.0 


10.2 


0.9 


28* 


♦24 


12.5 


11.6 


11.3 


12.5 


11.0 


1 1 .3 


24* 


♦25 


13.9 


12.9 


12.5 


14.0 


13.0 


12.0 


26 • 


♦26 


15.3 


14.2 


13.8 


15.5 


14.4 


14.0 


20* 


•27 


16.9 


15.7 


15.2 


17.2 


10.0 


16. S 


27" 


•28 


18.5 


17.2 


16.7 


1S.8 


17.5 


10.9 


28* 


•29 


20.2 


18.8 


18.2 


20.5 


19.1 


18.5 


2'J* 


•30 


21.7 


20.2 


19.6 


22.0 


20.5 


19.8 


90* 


♦31 


23.2 


21.6 


20.9 


23.4 


21.8 


21.1 


31* 


*32 


24.5 


22.8 


22.1 


24.8 


23.1 


22.:'. 


32* 


*33 


25.9 


24.1 


23.3 


26.0 


24.2 


23.4 


3:i* 


•34 


27.3 


25.4 


24.6 


27.3 


25.4 


24.6 


34* 


•35 


28.7 


26.7 


25.8 


28.6 


20.6 


25.7 


:',:>• 


•36 


30.0 


27.9 


27.0 


30.0 


27.9 


27.0 


30* 


•37 


31.6 


29.4 


28.4 


31.5 


29.3 


28.4 


37* 


♦38 


33.2 


30.9 


29.9 


32.7 


30.4 


29.4 


38* 


39 


36.3 


33.8 


32.7 


35.7 


33.2 


32.1 


39 


40 


38.1 


35.4 


34.3 


37.4 


34.8 


33.7 


40 


41 


39.8 


37.0 


35.8 


39.2 


30.5 


35.3 


41 


42 


41.7 


38.8 


37.5 


41.2 


38.3 


37.1 


42 


43 


43.5 


40.5 


39.2 


43.1 


40.1 


38.8 


43 


44 


45.4 


42.2 


40.9 


44.8 


41.7 


40.3 


44 


45 


47.1 


43.8 


42.4 


46.3 


43.1 


41.7 


45 


46 


49.5 


46.0 


44.6 


48.5 


45.1 


43.7 


46 


47 


51.4 


47.8 


46.3 


50.9 


47.3 


45.8 


47 


48 


53.0 


49.3 


47.7 


53.3 


49.6 


48.0 


48 


49 


55.4 


51.5 


49.9 


55.8 


51.9 


50.2 


49 


50 


59.6 


55.4 


53.6 


58.3 


54.2 


52.5 


50 


51 


62.5 


58.1 


56.3 


61.1 


56.8 


5. r ).0 


51 


52 


65.8 


61.1 


59.2 


63.8 


59.3 


57.4 


52 


53 


68.9 


64.1 


62.0 


66.8 


62.1 


60.1 


53 


54 


72.0 


67.0 


64.8 


70.3 


65.4 


03.3 


54 


55 


75.4 


70.1 


67.9 


74.5 


69.3 


07.1 


;" ." 


56 


79.2 


73.7 


71.3 


78.4 


72.9 


70.6 


56 


57 


82.8 


77.0 


74.5 


82.5 


76.7 


74.3 


57 


58 


87.0 


80.9 


78.3 


80.6 


80.5 


77.9 


58 


59 


91.1 


84.7 


82.0 


91.1 


84.7 


82.0 


59 


60 


95.2 


88.5 


85.7 


96.7 


89.9 


87.0 


60 


61 


99.3 


92.3 


89.4 


102.5 


95.3 


92.2 


61 


62 


103.8 


96.5 


93.4 


110.4 


102.7 


99.4 


62 


63 


108.0 


100.4 


97.2 


118.0 


109.7 


106.2 


63 


64 


114.7 


106.7 


103.2 


123.0 


114.4 


110.7 


64 


65 


121.8 


113.3 


109.6 


130.0 


120.9 


117.0 


65 


66 


127.8 


118.9 


115.0 


137.0 


127.4 


123.3 


66 


67 


132.0 


123.3 


119.3 


143.0 


133.0 


128.7 


67 


68 


138.9 


129.2 


125.0 


146.9 


136.6 


132.2 


68 



• Without clothing. 



305 





NUTRITION AND GROWTH IN CHILDREN 


Table II. — Average Weight and Height Measurements 


of Boys 






at Various Ages 




Age 


Height in 
Inches 


Weight in 
Pounds 


Age 


Height in 
Inches 


Weight in 








Pounds 


Years 


Months 






Years 


Months 






Birth 





♦20.6 


- * 7.55 


9 





50.0 


59.6 




2 


•22.5 


•10.4 


9 


2 


50.3 


60.6 




4 


•24.5 


•13.2 


9 


4 


50.6 


61.5 




6 


•26.5 


•16.0 


9 


6 


51.0 


62.5 




8 


•27.5 


•17.7 


9 


8 


51.3 


63.5 




10 


•28.5 


•19.3 


9 


10 


51.6 


64.4 







•29.5 


•21.0 


10 





51.9 


65.4 




2 


•30.3 


•22.1 


10 


2 


52.2 


66.3 




4 


•31.1 


•23.3 


10 


4 


52.5 


67.2 




6 


•32.0 


•24.5 


10 


6 


52.7 


68.0 




8 


•32.7 


•25.5 


10 


8 


53.0 


68.9 




10 


•33.4 


•26.4 


10 


10 


53.3 


69.8 


2 





•34.0 


•27.3 


11 





53.6 


70.7 


2 


2 


•34.7 


•28.2 


11 


2 


53.9 


71.7 


2 


4 


•35.4 


•29.1 


11 


4 


54.2 


72.7 


2 


6 


•36.0 


•30.0 


11 


6 


54.5 


73.8 


2 


8 


•36.5 


•30.8 


11 


8 


54.8 


74.8 


2 


10 


•37.0 


•31.6 


11 


10 


55.1 


75.9 


3 





•37.5 


•32.5 


12 





55.4 


76.9 


3 


2 


•38.0 


•33.2 


12 


2 


55.8 


78.2 


3 


4 


•38.5 


•34.0 


12 


4 


56.1 


79.5 


3 


6 


•39.0 


•34.7 


12 


6 


56.5 


80.8 


3 


8 


•39.5 


•35.4 


12 


8 


56.8 


82.1 


3 


10 


•40.0 


•36.1 


12 


10 


57.2 


83.5 


4 


♦40.5 


•36.8 


13 
13 



2 


57.5 
57.9 


84.8 


4 





39.5 


37.2 


86.5 


4 


2 


39.9 


37.9 


13 


4 


58.3 


88.3 


4 


4 


40.2 


38.5 


13 


6 


58.7 


90.0 


4 


6 


40.6 


39.2 


13 


8 


59.2 


91.8 


4 


8 


41.0 


39.8 


13 


10 


59.6 


93.5 


4 


10 


41.4 


40.5 


14 





60.0 


95.2 


5 





41.7 


41.2 


14 


2 


60.5 


97.2 


5 


2 


42.1 


41.8 


14 


4 


61.0 


99.3 


5 


4 


42.4 


42.4 


14 


6 


61.5 


101.3 


5 


6 


42.8 


43.1 


14 


8 


61.9 


103.3 


5 


8 


43.2 


43.8 


14 


10 


62.4 


105.3 


5 


10 


43.5 


44.5 


15 





62.9 


107.4 


6 





43.9 


45.2 


15 


2 


63.2 


109.7 


6 


2 


44.3 


45.9 


15 


4 


63.6 


111.9 


6 


4 


44.7 


46.6 


15 


6 


63.9 


114.2 


6 


6 


45.1 


47.3 


15 


8 


64.2 


116.5 


6 


8 


45.4 


48.1 


15 


10 


64.6 


118.8 


6 


10 


45.7 


48.8 


16 





64.9 


121.0 


7 





46.0 


49.5 


16 


2 


65.1 


122.5 


7 


2 


46.5 


50.3 


16 


4 


65.5 


124.0 


7 


4 


46.9 


51.2 


16 


6 


65.7 


125.5 


7 


6 


47.4 


52.0 


16 


8 


65.9 


127.0 


7 


8 


47.9 


52.8 


16 


10 


66.1 


128.5 


7 


10 


48.3 


53.6 


17 





66.5 


130.0 


8 





48.8 


54.5 


17 


2 


66.7 


130.9 


8 


2 


49.0 


55.4 


17 


4 


66.8 


131.7 


8 


4 


49.2 


56.2 


17 


6 


67.0 


132.6 


8 


6 


49.4 


57.1 


17 


8 


67.2 


133.4 


8 


8 


49.6 


57.9 


17 


10 


67.3 


134.3 


8 


10 


49.8 


58.8 


18 





67.4 


135.1 



• Without clothing. 



306 



TABLES OF WEIGHTS 



Table III. — Average Weight and Height Measubemeis tb of GlRLfl 
at Various Ages 



A 


ge 






Age 










Height in 
Inches 


Weight in 
rounds 






Height In 
Inches 


Weight In 










Pounds 


Years 


Months 






Years 


Months 






Birth 





•20.5 


• 7.10 


9 





49.7 


57.4 




2 


•22.3 


♦ 9.9 


9 


2 


50.0 


58.3 




4 


•24.2 


•12.7 


9 


4 


50.4 


59.2 




6 


•26.0 


•15.5 


9 


6 


50.7 


60.2 




8 


•27.0 


•17.2 


9 


8 


51.0 


61.1 




10 


•28.0 


•18.8 


9 


10 


51.4 


62.0 


1 





•29.0 


•20.5 


10 





51.7 


62.9 


1 


2 


•20.8 


•21.7 


10 


2 


52.1 


64.0 


1 


4 


•30.0 


•22.8 


10 


4 


52.4 


65.1 


1 


6 


•31.4 


•24.6 


10 


6 


52.8 


66.2 


1 


8 


•32.0 


•24.8 


10 


8 


53.2 


67.3 


1 


10 


•32.7 


•25.6 


10 


10 


53.5 


68.4 


2 





•33.4 


•26.5 


11 





53.8 


69.5 


2 


2 


•34.0 


•27.3 


11 


2 


54.1 


71.0 


2 


4 


•34.0 


•28.1 


11 


4 


54.5 


72.6 


2 


6 


•35.3 


•29.0 


11 


6 


54.9 


74.1 


2 


8 


•35.9 


•29.8 


11 


8 


55.3 


75.7 


2 


10 


•36.5 


•30.6 


11 


10 


55.7 


77.2 


3 





•37.0 


•31.5 


12 





56.1 


78.7 


3 


2 


•37.5 


•32.1 


12 


2 


56.5 


80.4 


3 


4 


♦38.0 


•32.7 


12 


4 


56.9 


82.0 


3 


6 


•38.5 


•33.3 


12 


6 


57.3 


83.7 


•> t 


8 


•39.0 


•34.0 


12 


8 


57.7 


85.4 


3 


10 


•39.5 


•34.6 


12 


10 


58.1 


87.0 


4 





•40.0 


•35.3 


13 
13 




2 


58.5 
58.9 


88.7 


4 





39.3 


36.2 


90.3 


4 


2 • 


39.7 


36.8 


13 


4 


59.2 


91.9 


4 


4 


40.0 


37.4 


13 


6 


59.5 


93.5 


4 


6 


40.4 


38.0 


13 


8 


59.8 


95.1 


4 


8 


40.7 


38.6 


13 


10 


60.1 


96.7 


4 


10 


41.0 


39.2 


14 





60.4 


98.3 


5 





41.3 


39.8 


14 


2 


60.6 


99.7 


5 


2 


41.6 


40.4 


14 


4 


60.8 


101.1 


5 


4 


41.9 


41.0 


14 


6 


61.0 


102.5 


5 


6 


42.3 


41.6 


14 


8 


61.2 


103.9 


5 


8 


42.6 


42.2 


14 


10 


61.4 


105.3 


5 


10 


42.9 


42.8 


15 





61.6 


106.7 


6 





43.3 


43.4 


15 


2 


61.7 


107.6 


6 


2 


43.7 


44.1 


15 


4 


61.8 


108.6 


6 


4 


44.1 


44.8 


15 


6 


61.9 


109.5 


6 


6 


44.5 


45.5 


15 


8 


62.0 


110.4 


6 


8 


44.9 


46.2 


15 


10 


62.1 


111.3 


6 


10 


45.3 


46.9 


16 





62.2 


112.3 


7 





45.7 


47.7 


16 


o 


62.3 


112.8 


7 


2 


46.0 


48.5 


16 


4 


62.4 


113.3 


7 


4 


46.4 


49.3 


16 


6 


62.5 


113.8 


7 


6 


46.7 


50.1 


16 


8 


62.5 


114.4 


7 


8 


47.0 


50.9 


16 


10 


62.6 


114.9 


7 


10 


47.4 


51.7 


17 





62.7 


115.4 


8 





47.7 


52.5 










8 


2 


48.0 


53.3 










8 


4 


48.4 


54.1 










8 


6 


48.7 


55.0 










8 


8 


49.0 


55.8 










8 


10 


49.4 


56.6 











Without clothing. 



307 



NUTRITION AND GROWTH IN CHILDREN 



Table IV. — Table Showing Increases 


in Weusht at 


Various 


Ages by Yeabs, Quarters, 


and Weeks 




BOYS 


Age 


Year — 52 Weeks 


Quarter — 
13 Weeks 


Week 












■ 




Pounds 


Ounces 


Pounds 


Ounces 


Pounds 


Ounces 


Birth to 1 year 


13.45 


215.2 


3.3625 


53.8 


.259 


4.14 


1 to 2 years 


6.3 


100.8 


1.575 


25.2 


.121 


1.94 


2 to 3 years 


5.2 


83.2 


1.3 


20.8 


.100 


1.60 


3 to 4 years 


4.3 


68.8 


1 .075 


17.2 


.083 


1.32 


4 to 5 years 


4.0 


64.0 


1.0 


16.0 


.077 


1.23 


5 to 6 years 


4.0 


64.0 


1.0 


16.0 


.077 


1.23 


to 7 years 


4.3 


68.8 


1.075 


17.2 


.083 


1.32 


7 to 8 years 


5.0 


80.0 


1.25 


20.0 


.096 


1.54 


8 to years 


5.1 


81.6 


1.275 


20.4 


.098 


1.57 


9 to 10 years 


5.8 


92.8 


1.45 


23.2 


.112 


1.79 


10 to 11 years 


5.3 


84.8 


1.325 


21.2 


.102 


1.63 


11 to 12 years 


6.2 


99.2 


1.55 


24.8 


.119 


1.91 


12 to 13 years 


7.9 


126.4 


1.975 


31.6 


.152 


2.43 


13 to 14 years 


10.4 


166.4 


2.6 


41.6 


.200 


3.20 


14 to 15 years 


12 2 


195.2 


3.05 


48.8 


.235 


3.75 


15 to 16 years 


13.6 


217.6 


3.40 


54.4 


.262 


4.18 


GIRLS 


Age 


Year— 5 


2 Weeks 


Quarter — 
13 Weeks 


Week 
















Pounds 


Ounces 


Pounds 


Ounces 


Pounds 


Ounces 


Birth to 1 year 


13.34 


213.44 


3.335 


53.36 


.257 


4.11 


1 to 2 years 


6.0 


96.0 


1.50 


24.0 


.115 


1.85 


2 to 3 years 


5.0 


80.0 


1.25 


20.0 


.096 


1.54 


3 to 4 years 


3.8 


60.8 


.95 


15.2 


.073 


1.17 


4 to 5 years 


3.6 


57.6 


.9 


14.4 


.069 


1.11 


5 to 6 years 


3.6 


57.6 


.9 


14.4 


.069 


1.11 


6 to 7 years 


4.3 


68.8 


1.075 


17.2 


.083 


1.32 


7 to 8 years 


4.8 


76.8 


1.2 


19.2 


.092 


1.47 


8 to 9 years 


4.9 


78.4 


1.225 


19.6 


.094 


1.51 


9 to 10 years 


5.5 


88.0 


1.375 


22.0 


.106 


1.69 


10 to 11 years 


6.6 


105.6 


1.65 


26.4 


.127 


2.03 


11 to 12 years 


9.2 


147.2 


2.3 


36.8 


.177 


2.83 


12 to 13 years 


10.0 


160.0 


2.5 


40.0 


.192 


3.08 


13 to 14 years 


9.6 


153.6 


2.4 


38.4 


.185 


2.95 


14 to 15 years 


8.4 


134.4 


2.1 


33.6 


.175 


2.59 


15 to 16 years 


5.6 


89.6 


1.4 


22.4 


.108 


1.72 



308 



TABLES OF WEIGHTS 

The tables on pages 305 and 308 are based upon 
those on pages 306 and 307. The material of the lat- 
ter for the first four years is taken from Holt's 
Diseases of Infancy and Childhood (1920) ; that for 
the succeeding years is derived principally from the 
work of Boas, Burk, Bowditch, and Smedley. The 
weights and heights in Holt's table are without cloth- 
ing, while those of the later years are with indoor 
clothing but without shoes. 

It will be noted that the figures for the later years 
differ from the Boas-Burk tables by six months. Our 
reason for setting the figures forward half a year is 
that in their original form they represent averages 
that include the very large number of children 
whom our clinical experience and studies of entire 
school groups find to be seriously malnourished. The 
tables in their present form run lower at the various 
ages than those made in studies concerned mainly 
with normal children. As they are here printed they 
afford the best working standard for use until such 
a time as sufficient data are secured from weighing 
and measuring a large number of children who are 
normal. 



NUTRITION AND GROWTH IN CHILDREN 

Table V. — Table Showing Weight of Childben's Clothing 
at Various Ages 



BOYS 





Indoor 


Age 


Clothing, 




Pounds 


3 


.75 


6 


1.5 


7- 9 


2.0 


10-12 


2.0 


13-15 


2.5 



Shoes, 
Pounds 



.25 
1.0 
1.25 
1.5 
1.9 



Outdoor 

Clothing, 

Pounds 



1.0 
1.0 
1.0 
1.5 
1.6 



Total 
Pounds 



2.0 

3.5 

4.25 

5.0 

6.0 



GIRLS 



Age 


Indoor 

Cloching, 

Pounds 


Shoes, 
Pounds 


Outdoor 

Clothing, 

Pounds 


Total 
Pounds 


3 
6 

7- 9 
10-12 
13-15 


.75 
1.25 
1.5 
1.75 
2.0 


.25 
1.0 
1.0 
1.0 
1.25 


1.0 

1.0 

1.25 

1.5 

1.75 


2.0 

3.25 

3.75 

4.25 

5.0 



These figures were secured by weighing children's 
outfits in a number of representative stores and check- 
ing the results by the weight of clothing actually 
worn. They indicate conditions in the month of May, 
midway between the extremes of winter and summer. 
Investigation shows that the difference in the weight 
of indoor clothing due to temperature or season 
seldom amounts to more than three-quarters of a 
pound at these ages. 

By "Indoor" clothing is meant the clothing usually 
worn in the house or at school, excluding coat and 
shoes, which should be removed before weighing. 
" Outdoor" clothing includes cap or hat and the coat 
previously referred to. The " Total" in the table 
is the sum of the three previous columns, thus repre- 
senting the child's entire outfit when he is out of 
doors. 

310 



APPENDIX II 

FORMS FOR NUTRITION RECORDS 



Name 






Age Yrs. Mos. 


Address 






Birthday 


School 






Grade 


Teacher 








Parent 










Height 


Average Height 




Weight 


Average Weight 


Underweight- 


-Normal- 


-Overweight % 








Date 



FORM I. INDEX RECORD CARD, SIZE, 3 BY 5 INCHES 

This form is used for the first record at the time of 
the weighing and measuring, before the nutrition 
class is formed. The cards may be grouped to show 
the number of children of average weight, the border- 
line cases less than seven per cent underweight, the 
malnourished who are seven per cent or more under- 
weight, and the overweight who are twenty per cent 
or more overweight for height. 

A system of classification with colored cards has 
been worked out by Dr. Burger, of the Physical Edu- 
cation Department of the Kansas City Schools, where 

311 



NUTRITION AND GROWTH IN CHILDREN 



CARD WHITE 
ALL RIGHT 



Name,.-*. 




Address — _... ..„ — ~- „...^.-..~^-..„^— 

Age„— .-^. .Years Months. Date of first weighing » _...~... 

Height....... »....inches. Weight pounds 

Average weight for height..... pounds 

Weigh yourself eaeh month and record belowr 



192 
September 

October 

November } 

December I 



Date 



Lbs. 



192 

January 

February 

March 

April 



Date 



Lbs. 



192 

May 

June 

July- 
August 



Date 



Lbs 



"ALL RIGHT" means 

that you are up to the average weight for your height. 

Try to come up to your "best weight" which is about ..pounds above 

the average. 

At your age you should gain about.,.,. pounds each. month. 

If you fail to gain properly or fall below the average find the cause and 



remove it. 

The chief causes for failure to gain are: 

Diseased adenoids and tonsils; lack of fresh air; over fatigue; late hours; 
not enough food of the right kind; fast eating; sweets between meals; the 
use of tea and coffee. 

FORM n. FRONT AND BACK OF WHITE CLASSIFICATION CARD. 
SIZE, 3 BY 4% INCHES 

each child is given a red, white, or blue card accord- 
ing to his condition. The cards bear the verse, 



Card of white, all right. 
Card of blue, won't do. 
Card of red, danger ahead. 
312 



FORMS FOR NUTRITION RECORDS 



CARD BLUE 
WON'T DO 



Name , » ~ ••••«• ~ 

Address -... - - - 

Age Years. „ Months. Date of first weighing , 

Height inches. Weight . pounds 

Average weight for height _ .....pounds. 

Weigh yourself each month and record below: 




192 
September 

October 


Date 


Lbs. 


192 
January 

February 

March 

April 


Date 


Lbs. 


192 

May 

June 

July 
August 


Date 


Lbs. 
























December 















"WON'T DO" means 

that while you are not greatly underweight for your height you are in danger 
of becoming more so unless you discover the cause and remove it. 

At your age you should gain about pounds each month. 

Already you are pounds underweight for your height. 

Take at least a pint of milk each day in one form or another. 

Gain in weight and change your blue card for one that is white. 

The chief causes for failure to gain are: 

Diseased adenoids and tonsils; lack of fresh air; over fatigue: late hours; 
not enough food of the right kind; fast eating; sweets between meals; the 
use of tea and coffee. 



FORM III. FRONT AND BACK OF BLUE CLASSIFICATION CARD. 
SIZE, 3 BY 4% INCHES 

We have made use of this system of classification, 
adding a fourth color to the series, "Card slate, over- 
weight,' ' with a statement on the reverse of each card 
giving instructions how to correct the abnormal con- 

313 



NUTRITION AND GROWTH IN CHILDREN 




CARD RED 
DANGER AHEAD 



Name » .*««r—. 

Address .... ....... - - » - 

Age............... Years . Months. Date of first weighing 

Height. inches. Weight ~ - pounds 

Average weight for height „ .. .-. pounds 

Weigh yourself each -month and record below: 



•192 
September 

October 


Date 


Lbs. 


192 
January 

February 

March 

April 


Date 


Lbs. 


192 

May 

June 

July 

August 


Date 


Lbs. 














November 
December 























"DANGER AHEAD" means 

(I .) Less endurance in games, sports and work. 

(2.) Less resistance to sickness. 

(3.) Probably always remaining underweight and underheight— • stunted. 

At your age you ought to gain: ~ ...pounds each month. 

You are already....- ....pounds underweight for your height. Find the cause 

and remove it! Gain in weight, change your red card for one that is 
blue. Then get one that is white as soon as you can. 

The chief causes for failure to gain are: 

Diseased adenoids and tonsils; lack of fresh air: over-fatigue; late hours: 
not enough food of the right kind; fast eating; sweets between meals; the 
use of tea and coffee. 

Things you can do : 

Take a quart of milk a day in one form or another. 

Take rest periods of at least half an hour before mid-day and evening meals. 
Take mid-morning and mid-afternoon lunches without sweets, not enough, 
lunch to spoil appetite for the next meal. 



FORM IV. 



FRONT AND BACK OF RED CLASSIFICATION CARD. 
SIZE, 3 BY 4y 2 INCHES 



dition. These colored cards arouse the interest of 
the children and stimulate all to work for white cards, 
the sign of normal condition. 

314 



FORMS FOR NUTRITION RECORDS 



CARD SLATE 
OVERWEIGHT 



Name.... - 

Address * - 

Age Years Months. Date of first weighing 

Height inches. Weight pounds 

Average weight for height pounds 

Weigh yourself each month and record below: 




192 
September 

October 

November 

December 


Date 


Lbs. 


192 
January 

February 

March 

April 


Date 


Lbs. 


192 
May 

June 

July 
August 


Date 


Lbs. 



































"OVERWEIGHT" means 

less endurance and efficiency in both play and work as well as lessened 
.attractiveness in appearance. v 

You should reduce your weight pounds and get a white card. It would 

be better to lose a few more pounds. 

Begin at once to reduce your weight to the normal. 

Take less of high value foods such as candy, pastry, cream and butter; also 
avoid eating between meals. 

Eat fruit and vegetables. 

Do not reduce more than" a pound a week. 

Work for a White Card! 



FORM V. 



FRONT AND BACK OF SLATE CLASSIFICATION CARD. 
SIZE, 3 BY 4% INCHES 



A buff card has also been adopted, Form VI, to 
hold the child's complete weight record, with the 
dates on which he receives the various colored cards. 

315 



NUTRITION AND GROWTH IN CHILDREN 



NUTRITION RECORD CARD 



Name,. 



.-Age Ye 



.._Month« 



Date of first weighing. 

Average weight for height. 



„ ~. Birth date 

,_ Weight ...pounds. 

pounds. Per cent 




Register below results of successive weighings: 



Height. inches. 

overweight.. ^..^-^,.._,„ 
underweight., 



192 

September 
October 
November 
December 



Date 



192 

January 
February 
March 
April 



Date Lbs. 



192 
May 

June 

July 

August 



Date 



Dates pupil received various colored cards: v- 

PILE THIS CARD IN OFFICE AND FELL IN RECORDS REQUIRED 
USB REVERSE SIDE FOR NOTES 



FOBM VI. NUTRITION RECOBD CABD (BUFF), SIZE, 3 BY 5 INCHES 

"When filed according to the color classification, these 
buff cards will then show constantly the proportion 
of overweight, underweight, borderline, and normal 
children in any group. 



FORMS FOR NUTRITION RECORDS 



MAlfB NutrlUoo CUa. Sdwol G...V 


ADDRESS «od Tcfepbao* Number Dim o> WrU. Uadtrwritkt lb. ▼. 


IplS 

Date 


i 


> 


3 


* 


5 


* 


7 


• 


* 


■ 


11 


13 


11 


14' 


II 


.6 


17 


la 


l» 


!0 


" 


" 


U 


>« 


11 


19 


Rut Pined* 






















































L«nvti- 






















































Us 






























































































































































































































































































































































































































































































































































































































































































































Calarla 













































































































Name 

Height in* Weight lb*. 

Actual 

Average 
Cxaained by Dr. 


Data 


Age yt» ooa 
Cained ox. m wk*. 
Cained in*, is wk*. 
Expected weekly gain ox. 
% actual of expected gain 


SUMMARY OF DEFECTS FOUND 

2 7 




DEFECTS CORRECTED Date* 


5 « 

4 9 

5 10 

FREE TO GAIN Ye* . Date No. 
HOME COOPERATION Good Fair 
SCHOOL PROCRAM 

Full time double aeasion hra. 

Full time tingle aeasion hra. 

How modified 


Uncertain 
Poor 


Previoua A, and T Operation*. Data* 
JUIUMK9 


LUNCHES mm) REST PERIODS (Man) 
Mid-mornmg wk*. wk* 
Mid-afternoon wk* wka. 
FOOD HABITS Take* milk pta daily 
> cereal daily occasionally 
HEALTH HABITS Bed time Riae* 




CHILD PARENT OR REPRESENTATIVE PHYSICIAN 
Attended wka. out of wka. wk*. out oi wka. wka. out of wk*> 



F0BM VII. 



FBONT AND BACK OF INDIVIDUAL WEIGHT CHABT. 
SIZE, 4 BY 6 INCHES 



The record on the face of this individual weight chart 
is copied from the large weight chart used in the nutrition 
class. The summary on the back is made at the end of 
the quarter or half year. This form can also be used for 
recording the average weekly gains of a class or group, 
being rendered more effective by a red line showing the 
average expected gain of the members of the group. 

317 



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318 



FORxMS FOR NUTRITION RECORDS 



Directions for Making Out the Weight Chart 

The Actual Weight Line. On the lower line of the 
square above the word "Calories" write the number 
of pounds that the child weighs. On each of the lines 
above this increase the figure by one. Fill in the dates 
of the weekly weighings on the top horizontal line. 
In the column under the date of the first weighing 
place a dot in the square opposite the figure indicat- 
ing the child's weight — even pounds on the lower line, 
half pounds on the middle line, and quarters in the 
spaces between. Disregard all fractions less than one- 
quarter of a pound. Continue to record the weekly 
weighings in the same way. Connect each new dot 
by a straight line with the dot recording the previous 
weighing and thus construct the child's actual weight 
line. 

The Average Weight Line. From the table of 
weights at various heights (page 305) find the average 
weight for the child's height, and indicate by a dot 
opposite that figure on the middle vertical line in the 
column under the first weighing date. From the table 
showing increases in weight (page 308) determine the 
expected gain for 13 weeks according to the age of 
the child, and indicate by a dot on the middle ver- 
tical line of the proper square in the column under 
the thirteenth weighing date. Connect these two dots 
by a straight line extending across the remainder of 
the chart at the same angle. This is the average 
weight line. 

When the actual weight line reaches the average 
weight line, the child should be measured again, and 

319 



NUTRITION AND GROWTH IN CHILDREN 

if he has grown in height during the interval, a new 
average weight line based on his new height should be 
computed. He should be graduated only when he has 
attained the weight required by his new height. 



FRITiON 

({NATION 
ibmt? condition 



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Cerumen — rig 



Cerumen— lef 



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d pulm. accentv 
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,id. axillary liae 
jgle ol scapula 

hrougiout 

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FORM FOR HISTORY AND PHYSICAL EXAMINATION nutrition clinics for delicate ch.ldren 



INIOItMMIOM RtGUtDINf, MEMBERS of FAMILY 



INSPECTION Bright 



-phlegmatic- apatlu' 



SUMMARY OF DEFECTS FOUND 



Name 


Living 


Healtli 


Defc 1, 


Remarks -l„ Case ,.r Death GENERAL CONDITION Good-fair-poor Line? under eyes Undeuvveiout Fob HEioor PuoNna I'kwumt 
Give Date. Ace anil ( ause 





Mouth breather 


fsllior — 








MUSCLES Riceps 6rm— flabby Posture Ereel— fatigue Otheu Defects 




Nasal voice 


Mother 








HEAD Normal Bosses prominent Ped culi 


Signs of" 


Granular pharynx 


Cliildren 








EYES Pupils equal— unequal React to light— distance Mi.tions normal— abnormal 


Nasopharyngeal 


Cryptic toosili 










Vision Right /SO Lett /«0 '.Snellen's test) 


Obstruction 


Bolarged ant,— 










NARES Clear— crusted— mucous discbarge— spur— deviated septum 




cervical glands 


4 








MOUTH Normal— open Cough Herpes Mu-ous membrane. Normal-pale 




Eardrums dull 










TONGUE Normal— moist— dry— brownish coat 







Use lower spaces t 



In.-lu.lc still-born 



jWFn pMATlON REGARDING DIRTH AND INFANCY 



rmal — large — buried — cryptic 



inflamed — absent 



Bern „ t f„H t fr m 



GLANDS Normal— enlarged, ant-. 



RECOMMENDATIONS 



TEETH. Good— Number carious 



Approximation: Good — poor 



EARS Right drum: Normal— dull— retracted— bulging 



Left drum: Normal— dull— retracted— bulging Cerumen— left 



PREVIOUS DISEASES (WITH DATES) 



HEART Area dullness 



. left mid-sternal lit 



EXAMINED BY 



RE('"OHI)l-:i) BY 



Otitis (Earache) 



Apex 4th— 5th— 6th— space in mid-clavicular lit 



FURTHER EXAMINATION (io case of failure to gain) 



. outside mid-clavicular line 



X-Roy of Chest. Digestive Tract. 



. inside mid-clavicular line 



Special Nose. Throat and Sinus 



Action: Regular — irregular 



ally Red Cells and Hemoglobir 



Murmurs: None 



GENERAL HEALTH AND HABITS 
General Health: Good— fair— poor 



loud systolic at \ pulmonic 



id pulm. accentuated 

axillary line 
mid. axillary line 



Wassertnan Reactioo 
Temperature Chart Record 



Skin Teats for Proteins 



How long underweight 



Repeated attacks indigestii 



; good throughout Respira 



[ angle of scapula 
l good throughout D'Espine 



Stools for Parasites, etc. 



ADDITIONAL NOTES ON PHYSICAL EXAMINATION 



Candy or sweets between meals 
Does child take cereals? 



Washing down food 



ABDOMEN: Normal— large— distended -tympanitic— tender— btrnie 
) costal border mid-clavicular lii.e 



LIVER: Dullness 



Sleep: Month open— quiet— restless— sm 



How otten laxatives used 



GENITALS: Normal Prepuce. Long— adherent— circjtmrised 

EXTREMITIES: K J : Present and equal-absent Edema^ Pre sent-absent 



meals: Breakfast 



SKIN: Smooth— rough— cl 



Vaccination: Present-absent 



Average number hours in 24 spent 



PRESENT SYMPTOMS 



SPINE: Normal— rigid— curvature — round shoulders 
CHEST: Normal— barrel— flat— funnel— pigeon 



FEET: Arches: Good— flat 



TEMPERATURE: 



Albumen 
HEIGHT: 



R. P. IMEHSON. 



Form ix front of 



HISTORY AND PHYSICAL EXAMINATION FORM. SIZE, 14% BY 8 INCHES. 



SOCIAL DIRECTIONS FOR THE USE OF THIS FORM WILL BE FOUND IN CHAPTER IV. 




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321 






Supplementary Notes: 



NUTRITION CLINICS FOR DELICATE CHILDREN 
Report of Nutrition Class 

Name of Class 

Date — from, to ^21 

Reporter _ 

(A report is due every two weeks) 



Members enrolled 


Week I 


Week II 


Members present 






Number gaining 












Number unchanged or losing . . 


















Physician present : Yes — No 
























Number waiting physical examination . . 













(Over) 

FORM XI. FORTNIGHTLY REPORT OF NUTRITION CLASS. 
SIZE, 4% BT 9% INCHES 

322 



FORMS FOR NUTRITION RECORDS 

The form shown opposite is useful in checking up 
a class to see that the essentials of the nutrition pro- 
gram are being carried out. It shows whether the 
children are following directions, and the status of 
the group with respect to physical examinations, 
necessary operations, and gains made. The reverse 
of the blank is shown below. 



DIRECTIONS 

Date first fortnightly report from the day of the first 
weighing to that of the third weighing. Week I closes with 
second weighing and Week II with third. 

Count for first enrollment all present at second weighing 
whom you have decided to admit to the class. 

Remove from the official roll names of all children absent 
for two consecutive weeks. (This does not mean that the 
nutrition worker is to discontinue visits or in any way lose 
connection with the family.) Reenroll them when they return 
to class. 

In determining ounces gained or lost by children who have 
been absent divide the gain or loss since the last weighing by 
the number of weeks and enter the result in the proper column. 

In determining average gain for the week, subtract ounces 
lost from ounces gained and divide the remainder by the num- 
ber present. 



NUTRITION AND GROWTH IN CHILDREN 



NUTRITION CLINICS FOR DELICATE CHILDREN. Incorporated 

44 DWIGHT STREET. BOSTON 



QUARTERLY REPORT TO GENERAL SECRETARY 




Name of dan Report for 13 weeks from 192 


to 192 


Address School 


Grade 


Nutrition worker Physician Principal 


RESULTS OF WEIGHING AND MEASURING CROUP FROM WHICH CLASS WAS FORMED 


BOYS CIRLS 


Bomsuts 


Children weighed and measured No 100% No, , 100% 

Normal weight (average to 20% 

over inclusive) No.. , ■ , % No % 


No, 100* 

No % 


Borderline (les* than 7% under) No — — % No - % 


No % 


Underweight (7% and more) 'No. — — % No — — % 


No, % 


Overweight (more than 20%) No. % No. % 


No % 


Average number of phvsical defects (divide total number of defects by number of cases examined) 




Physician present out of 13 meetinw. Total number visits made by parent* 


Explanation of all cases dropped 









Notes: (Predominant n a t ionality of group, economic condition (whether well-to-do or poor, etc) 

FORM XH. FRONT PAGE OF QUARTERLY REPORT OF NUTRITION 
CLASS. SIZE OF BLANK FOLDED, 8% BY 11 INCHES 

This report furnishes a class summary in such 
form that the results may be compared with similar 
data from other groups. The second page of the 
blank is shown opposite. 



324 



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325 



APPENDIX III 

GLOSSARY 

Acne. An inflammatory disease of the sebaceous 
glands, occurring mostly about the face, chest, and 
back. 

Adenoid. A mass of tissue situated at the posterior 
wall of the upper end of the pharynx; known as 
the pharyngeal tonsil. 

Adherent prepuce. Abnormal tightness of the fore- 
skin. 

Alveolar abscess. A collection of pus in a tooth 
socket or cavity. 

Anaphylaxis. Increased susceptibility to the action 
of a foreign proteid introduced into the body, in- 
duced by a first injection of the same substance. 

Anemia. A condition in which the blood is reduced 
in amount or is deficient in red blood cells. 

Antineuritic. Effective in the treatment and preven- 
tion of neuritis. 

Antirachitic. Effective in the treatment and preven- 
tion of rickets. 

Antiscorbutic. Effective in the treatment and preven- 
tion of scurvy. 

Antrum. A nearly closed cavity in the superior 
maxillary bone, communicating with the middle 
passages of the nose. 

Calory. The heat unit employed in the study of 
metabolism; the amount of heat required to raise 
326 



GLOSSARY 

the temperature of one kilogram of water one de- 
gree centigrade. 

Carbohydrate. A substance containing carbon, hy- 
drogen, and oxygen, the two latter in the propor- 
tion to form water. The sugars, starches, and cel- 
lulose belong to the class of carbohydrates. 

Cardiac. 1. Relating to the heart. 2. Relating to the 
esophageal orifice of the stomach. 

Cardiospasm. Spasmodic contraction of the cardiac 
end of the stomach or of the adjoining portion of 
the esophagus. 

Carious. Decayed or decaying. 

Cerumen. Ear wax; the soft, brownish yellow secre- 
tion of the glands of the external auditory canal. 

Cervical. Relating to the neck. 

Chorea. St. Vitus* dance; a nervous disorder, usually 
occurring in childhood, characterized by irregular, 
spasmodic, involuntary movements of the limbs or 
facial muscles. 

Duodenum. The first division of the small intestine, 
in adults about 11 inches or 12 fingerbreadths 
(hence the name) in length. 

Eczema. An inflammation of the skin often accom- 
panied by itching or burning. 

Emphysema. A swelling due to the presence of air 
in the interstices of the connective tissue of a part. 

Endocarditis. Inflammation of the endocardium, or 
lining membrane of the heart. 

Endocrine glands. Glands which furnish an internal 
secretion to the body. 

Enuresis. Involuntary passage of urine. 

Eosinophilic An increase beyond the normal in the 
number of blood cells that stain readily with eosin. 

327 



NUTRITION AND GROWTH IN CHILDREN 

Esophagus. The gullet ; a museulo-membranous canal 
extending from the pharynx to the stomach. 

Exacerbations. The periodical aggravation of the 
febrile condition in remittent and continued fevers. 

Focal infection. An infection confined ordinarily to 
a distinct location, such as the tonsils or tooth 
sockets, from which at times microorganisms or their 
toxins escape to infect other regions or the general 
system. 

Fulminating appendicitis. Appendicitis marked by a 
sudden onset with rapid and fatal development. 

Gastritis. Inflammation of the stomach. 

Gingivitis. Inflammation of the gums. 

Hypertrophic. Marked by overgrowth or general in- 
crease in bulk of a part or organ. 

Infantilism. Retardation of mental and physical de- 
velopment; the persistence into later years of the 
characteristics of childhood. 

Intraspinal. Within the spinal canal or spinal cord. 

Intravenous. Within a vein or veins. 

Leucocyte. A colorless cell-mass, such as a white 
blood corpuscle, or one of the irregular cells found 
in the blood, the lymph, in pus, or as wandering 
connective cells in the tissues of the body. 

Malocclusion. Abnormal closing of the teeth; a mis- 
fit of the masticatory surfaces. 

Mastoiditis. Inflammation of the bony structure of 
the temple situated below and behind the orifice 
of the ear. 

Naso-pharyngeal. Pertaining to that part of the 
pharynx above and behind the soft palate, directly 
continuous with the nasal passages. 

Nephritis. Inflammation of the kidneys. 

328 



GLOSSARY 

Otitis. Inflammation of the ear. 

Otoscope. An instrument for examining the ear. 

Pediculosis. Lousiness; a skin disease produced by 

lice. 
Peritonitis. Inflammation of the peritoneum or sac 

lining of the abdominal cavity. 
Pharyngitis. Inflammation of the mucous membrane 

and underlying parts of the throat. 
Phlyctenular keratitis. Inflammation of the cornea, 

or outer coat of the eyeball, accompanied by the 

formation of pustules or blisters. 
Proteid. One of a group of substances constituting 

the greater part of the animal and vegetable tis- 
sues, all containing carbon, hydrogen, nitrogen, and 

oxygen, and some containing in addition iron, 

phosphorus, or sulphur. 
Ptosis. A falling or sinking down of any organ. 
Pyelitis. Inflammation of the pelvis of the kidney. 
Pyloric stenosis. A narrowing of the aperture between 

the stomach and the small intestine (duodenum). 
Radiograph. The record made on a photographic 

plate by the Roentgen rays or rays proceeding from 

radium or other radioactive bodies. 
Rickets. A disease occurring in infants and young 

children, characterized by softening of the bones. 
Sinus. A hollow cavity or channel in the cranial 

bones communicating with the nose. 
Syphilis, hereditary. An infectious venereal disease 

existing in a child at birth. 
Thyroid. A ductless gland lying in front of the 

trachea which furnishes an internal secretion of 

influence upon metabolism and important in the 

economy of the body. 



NUTRITION AND GROWTH IN CHILDREN 

Tonsil. A small mass of tissue situated on either side 
of the passage between the mouth and the pharynx. 

Toxemia. Blood poisoning caused by the poisonous 
products of the body cells or the influence of micro- 
organisms. 

Trachea. The principal air passage of the body ; the 
windpipe extending from the larynx to the bron- 
chial tubes, connecting through these with the lungs. 

Vaginitis, gonorrheal. Inflammation of the vagina or 
genital canal in the female, due to a specific infec- 
tion of the mucous membrane. 

Visceroptosis. Abdominal ptosis; an abnormal sink- 
ing down of the abdominal organs. 

Description of Tests 

Cutaneous proteid test. The application to the skin 
of the extract of various proteids to determine the 
reaction of the individual, which is indicated by a 
skin eruption. 

Roentgen-ray test. A shadow picture made by plac- 
ing the part to be examined between the Roentgen 
rays and a sensitized film or plate. The rays pene- 
trate many substances, as the flesh, that are im- 
pervious to ordinary light rays, but bone and other 
substances which are impervious to the Roentgen 
rays cast a shadow on the plate and form a picture. 

von Pirquet test. The inoculation with tuberculosis 
toxin, which causes more marked inflammatory re- 
action on the skin of tuberculosis subjects than of 
normal persons. 

Wassermann test. A diagnostic test for syphilis, 
based upon the theory of complement fixation, car- 
ried out upon blood samples. 
330 



APPENDIX IV 

list of publications of nutrition clinics for 

delicate children, incorporated, 44 dwight 

street, boston 

Forms 

NO. 

I. Index record card, 3 by 5 inches. 

II. White classification card, 3 by 4*/2 inches. 

III. Blue classification card, 3 by 4% inches. 

IV. Red classification card, 3 by 4% inches. 
V. Slate classification card, 3 by 4% inches. 

VI. Nutrition record card (buff), 3 by 5 inches. 
VII. Individual weight chart, 4 by 6 inches. 
VIII. Weight chart for use in nutrition classes, 18 by 24 
inches. 
IX. History and physical examination form, 14% by 8 
inches. 
X. Registration and visible record form, 19 by 24 inches. 
XI. Fortnightly report of nutrition class, 4% by 9% 

inches 
XII. Quarterly report of nutrition class, 8% by 11 inches, 
folded. 

XIII. Tables of weight in relation to height and age, 4% 

by 6 inches, folded. 

XIV. Nutrition class diploma, 5% by 7% inches. 

331 



NUTRITION AND GROWTH IN CHILDREN 

Pamphlets 

1. "A Nutrition Clinic in a Public School," by William 

R. P. Emerson, M.D. 

2. "Nutrition Clinics and Classes: Their Organization and 

Conduct," by William R. P. Emerson, M.D. 

3. Record Book for Measured Feeding, by William R. P. 

Emerson, M.D. 
7.* "Defective Nutrition and Growth: A Selected Bibli- 
ography," by Frank A. Manny. 
8. "Physical Defects in Children : Report of Six Hundred 
aud Two Cases," by William R. P. Emerson, M.D. 

14. "Practical Mental Examinations for Growing Chil- 
dren," by A. Warren Stearns, M.D. 

17. "Malnutrition in Children: Report of a Clinic," by 
William R. P. Emerson, M.D. 

20. "How to Organize a Local Nutrition Center." 

24. f "The Essentials in Diet for Good Nutrition," by Prof. 
E. V. McCollum. 

26. "Weight and Height in Relation to Malnutrition," by 
William R. P. Emerson, M.D., and Frank A. 
Manny. 

* Out of print. 
t In preparation. 

The serial numbers omitted have either been super- 
seded by other pamphlets, or the material covered has 
been incorporated in the chapters of this book. 



INDEX 



An asterisk attached to a number denotes that an illustration 
of the subject will be found on or facing the page indicated. 



Absorption, 84, 107-08, 242- 
44 

Activities outside school, 87, 
270; see also Forty- 
eight hour list of ac- 
tivities 

Actual weight line, see 
Weight chart 

Adenoids and tonsils, 29, 
30,* 34, 148-49, 165, 
218, 259, 267 

Age and defect, see Defects 
at various ages 

Age and height, see Height 
and age 

Age and weight, see Weight 
and age 

Air, see Bad air, Open air, 
Indoor air 

American Red Cross, At- 
lanta, xvi 

Anaphylaxis, 34, 121, 170- 
71 

Animals, care of, 81 
feeding of, 121-22 

Appetite, 117-19 

Assimilation, see Absorp- 
tion, Digestion 

Athletics, 136, 142-43; see 
also Camp life, Ex- 
ercise 



Atlanta, Georgia, xvi, 284 
Average weight, see Weight 

standards 
Average weight line, see 

Weight chart 



Bad air, viii, xi, 125*; see 
also Sleeping condi- 
tions 

Balanced diet, see Diet, bal- 
anced 

Bathing, 132 

Bed-wetting, see Enuresis 

Beef juice, 112 

Berkeley Infirmary, Boston, 
xi, 290,* 299 

Blanks, see Forms and 
blanks 

Boas, Franz, 309 

Borderline cases, 16-17, 284- 
87 
mental, 49 

Boston, Mass., vii, xv, 284, 
293-94; see also 
Berkeley Infirmary, 
Little Wanderers' 
Home, Massachusetts 
General Hospital, and 
names of other Bos- 
ton organizations 



333 



INDEX 



Boston Dispensary, vii 

Boston Tuberculosis Associ- 
ation, xv, 299 

Bowditch, H. P., 309 

Boy Scouts, 66, 137, 261, 
272 

Breakfast, 85, 95-96, 119, 
247 

Breathing, obstructions to, 
see Naso-pharyngeal 
obstruction 

Bureau of Educational Ex- 
periments, New York, 
xiv, 32 n. 

Burger, Fred, 311 

Burk, F. L., 309 



California, xvii 

Calories, table of, 100-06 

Camp life, 119, 140-42, 226, 
252-55 

Candy, 23, 34, 113*-14 

Cardiospasm, case of, 224* 

Case history, 21-24, 37-39, 
52-54; see also List 
of illustrations 

Cereals, 52,* 109, 111,* 176, 
278 

Chicago, 111., xv, 34,* 141,* 
254,* 260,* 284, 291,* 
294-96 

Child's own interest, viii, 
68, 183-86,* 211; see 
also Training for 
health 

Class method, vii, 183, 191- 
92; see also Nutri- 
tion class 

Cleveland, O., xvi, 296 



Climate, 10, 97 

Clinic organization, see 
Hospital organiza- 
tion, Nutrition clinic 

Clinical evidence, of malnu- 
trition, 7, 28 
of mental defect, 44 
of normal weight, 7, 8* 
of overweight, 19, 156 

Clothing, 130-31 
weight of, table, 310 
See also Shoes 

Clubs, 66, 87, 270 

Cocoa, 171-72 

Coffee, see Tea and coffee 

Community organization, 
256-65; see also 
School conditions 

Competition, spirit of, 76, 
86, 183 

Constipation, 129, 172-73 

Contagious diseases, 23, 147- 
48, 167, 275-76, 280 

Cooking, x 

Corrective exercises, 137-38 

Crum, F. S., 147 n. 

Cutaneous proteid test, 34, 
171, 330 



Dancing, 88, 136 
Dartmouth College, xvii 
Davidsohn, H., 280 
Dayton, O., 285 
Defects, 25, 27-28, 40* 

at various ages, 34, 148- 
49 

brought out by examina- 
tion, 34,* 37-41 

denned, 167 



334 



INDEX 



Defects in overweight and 
underweight com- 
pared, 156-58 
See also Malnutrition, 
signs of, Medical de- 
fects, Mental defects, 
Naso-pharyngeal ob- 
struction, Physical 
defects, Postural de- 
fects, Teeth defects 

Deformity, 34* 

Diagnosis of malnutrition, 
see Case history, 
Mental examination, 
Physical-growth ex- 
amination, Social ex- 
amination 

Diagnostic clinic, see Nutri- 
tion clinic 

Diet, viii-ix, 107-22, 151, 
191, 198, 246, 289* 
balanced, 109-10 
in overweight, 160-61 
See also Absorption, 
Food, Measured feed- 
ing 

Digestion, 96-97, 170-71, 
see also Absorption 

Diphtheria, 147 

Diploma, 190* 

Drafts, 128, 200, 278 

Drugs, 16, 118, 128-30, 151, 
171-72 

Duodenal bands, case of, 
28,* 219-20 



Employment certificates, 
candidates for, 141,* 
254*-55, 257, 260* 



Endocrine glands, see Glands 

Enuresis, 173-74 

Essentials of health, ix, 5, 
63-68 

Examination, see Mental ex- 
amination, Physical- 
growth examination, 
Social examination 

Exercise, 63, 134-45, 253-54 
for overweight, 161 
See also Gymnastics 

Extension service, 260-61 



Family history, 22 
table, 116 
types, 49, 201-04 
Fast eating, 115-16 
Fathers' and Mothers' Club, 

Boston, xv 
Fatigue limit, 80-81, 143-44 
posture, 8, 28 
See also Overfatigue 
Fears, 72, 75-76, 276, 278 
Fisher, Irving, xi, 91, 273 

n., 274 n. 
Fisk, E. L., 274 n., 
Focal infection, 31 
Food, amount needed, 90, 
96, 99, 107 
aversions, 119-21, 171 
exhibit, 92* 

habits, ix-xi, xiii, 23, 55, 
70*, 93, 107-22, 151- 
52, 270 
poisoning, see Anaphy- 
laxis 
values, 90-92 
in 100 calory portions, 
table of, 100-106 



335 



INDEX 



Foods essential to growth, 
110 

Forms and blanks, 311-325, 
331 

Forty-eight hour diet list, 
92, 108-09, 186 

Forty-eight hour list of ac- 
tivities, 51, 82-83 

Foster homes, 57*-58, 250- 
52 

"Free to gain," 8, 67, 234 

Fresh air, see Open air 

Fruit, 112, 176 



Gain, see Group gains, In- 
dividual gains, Per- 
centage, actual, of ex- 
pected gain 
Games, 134-36, 138 
Girl Scouts, 66, 137, 261, 

272 
Glands, endocrine, 159 
enlarged, 29, 165-66 
Glossary, 326-30 
Graduation, 20, 186, 190 
Grand Rapids, Mich., xvi, 

292,* 296-97 
Greeley, R. L., xiii 
Group gains, 141,* 289*- 

92,* 299 
Growth, 16-17, 82 
rapid initial, 7,* 10 
rate of, 10 
table, 308 
seasonal, 139 

See also Group gains, 
Height, Individual 
gains, Malnutrition 
and growth, Over- 



weight, Percentage 
actual of expected 
gain, Physical-growth 
examination^ Stunt- 
ing, Underweight 
Gymnastics, 136, 235; see 
also Corrective exer- 
cises; Setting-up ex- 
ercises 



Habit, see Food habits, 
Health habits, Regu- 
larity 

Habitual underweight, see 
Underweight, habit- 
ual 

Hawaiian Islands, xvii 

Health education, 153, 224, 
227, 239-40, 245-46, 
256, 279-81, 300 

Health, essentials of, see 
Essentials of health 
habits, xiii, 23, 55, 123- 

33, 151-52, 271 
training for, see Training 
for health 

Hebrew, lessons in, 88 

Height and age, 12-13, 18,* 
20 
table of, 306-07 

Height and weight, see 
Weight and height 

Height, how to measure, 
16,* 19 

Heredity, viii, x-xii, 6, 16, 
20,* 52,* 161 

Hess, A. F., 177 n. 

History, see Case history, 
Family history 



336 



INDEX 



Holt, L. E., 309 
Home conditions, ix, 55, 66 
control, xiii, 69-79, 150, 
209-10, 213, 218-19, 
267-68, 299-300 
visits, xi, 189, 198-201 
Hospital organization, 38, 
40-41, 223-24, 258-59 



Illinois, 285; see also Chi- 
cago 

Increase in weight, see 
Group gains, Growth, 
rate of, Individual 
gains, Percentage, ac- 
tual, of expected gain 

Individual gains, 7* 9* 
18,* 185,* 260,* 288,* 
300 

Indoor air, 125-28 
amusements, 138 

Infant care not continued, 
3, 146, 274-75 

Infection, see Contagious 
diseases, Focal infec- 
tion, Sinus infection 

Initial gain, see Growth, 
rapid initial 

Institutions, 249-52, 299-300 

Interest, child's own, see 
Child's own interest 
in children, 204-05 

Internal secretions, see 
Glands, endocrine 

International Child Welfare 
Conference, xv 



Joslin, E. P., 158 



Labrador, xvii, 285, 297-98 
Lack of home control, see 

Home control 
Laxatives, 129, 151 
Liquids, 114; see also Milk, 

Tea and coffee, Water 

drinking 
Little Wanderers' Home, 

Boston, xv, 126-27*, 

149, 284 
Lunches, see Mid-morning 

and mid-afternoon 

lunches, School 

lunches 



McCollum, E. V., 120, 178, 

332 
McCormick, Elizabeth, Me- 
morial Fund, Chica- 
go, xv-xvi, 34*, 141* ; 
see also Chicago 
Malnutrition and growth, 

3-11 
Malnutrition and tubercu- 
losis, 266-72 
Malnutrition, causes of, viii- 
xiii, xix, 4-6, 10, 71, 
123, 223 
defined, 6 

effects of, 6, 228-29 
extent of, xviii, 3-4, 230, 
282-87 
table, 284-87 
how to identify, 12-20 
rule for determining, 14 
signs of, 6-8, 28-29, 43- 

44, 130 
See also Defects, Under- 
weight 



337 



INDEX 



Manchester, N. H., 285 

Manny, F. A., xiv, 332 

Massachusetts General Hos- 
pital, Boston, xv, 40*, 
149 

Mastication, 114 

Masturbation, viii, xii, 72- 
73 

Measles, 147-48, 167 

Measured feeding, xi, 89- 
106 
the remedy for over- 
weight, 159-60 

Measuring height, 16*, 19 

Meat, 112 

Medical care, 67-68 
defects, 32-34 

Mendel, L. B., 15 

Mental defects, 22-23, 43- 
50, 202, 205 
examination, 43-50 
fatigue, 143 
tests, 47-48 

Metabolism, see Absorption, 
Digestion 

Mid-morning and mid-after- 
noon lunches, 98, 189, 
242-43* 

Milk, 52*, 108, 110-12, 115 
amount needed, 175 

Mineral salts, 110 

Morbidity statistics, 273-74 

Mortality statistics, 147, 273 

Mothers, work with, 153, 
209-13 ; see also 
Home control, Par- 
ents 

Mouth breathing, 28-29 

Mudge, G. G., 191 n. 

Music lessons, 88 



Naso-pharyngeal obstruc- 
tion, 29, 67, 148-49; 
see also Adenoids and 
tonsils, "Free to 
gain," Sinus infec- 
tion 
New Hampshire, xvi; see 

also Manchester 
New York City, xiv, 285, 

298 
New York Association for 
Improving the Condi- 
tion of the Poor, 
xiv 
Nutrition camp, 141*, 225- 
26, 251-54*, 257, 
260*, 292* 
class, vii-viii, 65, 183-92, 
208-14 
for pre-school child, 

152, 154 
report of a meeting, 
215-21 
clinic, 222-27, 233-34, 
258-59 
Nutrition Clinics for Deli- 
cate Children, Incor- 
porated, xv, 331 
Nutrition institutes, xv-xvi 
program, xiii 
outlined, 11 
for adults, 261-62 

in camp, 141*-42, 252- 

55 
in institutions, 249-50 
in the school, 230-33, 
240, 257 
worker, 186, 193-206, 207- 

09 
See also Malnutrition 



338 



INDEX 






Obesity, see Overweight 

Object lesson, use of, 188, 
210* 

Obstructions to breathing, 
see Naso-pharyngeal 
obstruction 

Open air, 124, 134, 139, 144, 
268 

Open-air schools, 124, 188, 
234 

Outside activities, see Activ- 
ities outside school 

Overfatigue, xiii, 43, 45, 54, 
80-88, 144, 150, 229, 
253-54 
cases of, 52-54, 216-21, 

236*, 247, 268-70 
See also Exercise, Fa- 
tigue, Play, Rest, 
School Program 

Overweight, 19-20*, 155-62* 

Overwork, 144-45 



Parallelogram of forces, 

64*-65 
Parents, 25, 186, 193, 195, 
227, 234, 240 

inspection by, 24, 27 

presence of, 21, 187, 224- 
26, 228, 230, 247 

responsibility of, 67, 78, 
226-27 

See also Home control, 
Mothers 
Percentage, actual, of ex- 
pected gain, formula 
and table, 293-98; 
see also Group gains, 
Individual gains 



Percentage of underweight, 

see Borderline cases, 
Seven per cent un- 
derweight test, Ten 
per cent underweight 
test 

Physical defects, xiii, 41% 
67, 148-49, 209, 267; 
see also Defects, 
"Free to gain" 

Physical-growth examina- 
tion, 25-42, 144, 276, 
320* 

Physical unfitness in Army, 
xviii, 4 

Physician, xvii-xviii, 195-96, 
208-14, 233 

Pictures before and after 
treatment, 41-42, 44*, 
184*, 186* 

Pirquet, von, test, xii, 33, 
330 

Play, 82, 134-35 

Postural defects, 137-38 

Posture, fatigue, see Fa- 
tigue posture 

Poverty, viii-ix, 6 

Pre-sehool age, 136, 146-54 

Preventive medicine, xvii, 
257, 273-81 

Price, Minnie, 191 n. 

Problem cases, 28*, 196, 
219-20, 222-24*, 258 

Program, see Forty-eight 
hour list of activities, 
Nutrition program, 
Summer program 

Proteid, 111-12 

test, see Cutaneous pro- 
teid test 



339 



INDEX 



Ptosis, see Visceroptosis 
Publications, list of, 331-32 
Punishment, 77-78 



Reading, 70, 138 
in bed, 52-53, 247 

Records, see Forms and 
blanks 

Recreation, 134-45 

Regularity, 85, 117, 122, 
133, 270 

Religious exercises, 66, 87 

Reports, see Forms and 
blanks 

Rest, 83, 133, 168, 188, 220- 
21, 268, 278 
periods, 83-84*, 169, 189, 

235 
See also Overfatigue, 
Sleep 

Results, 189-91, 204, 244, 
249-50, 275, 282-301 
table of, 293-98 
See also Group gains, In- 
dividual gains 

Retardation, see Mental de- 
fects, Stunting 

Rochester, N. Y., xvi, 259- 
60, 285 

Roentgen-ray, see X-ray 

Rose, M. S., 191 n. 

Rule for determining mal- 
nutrition, see Malnu- 
trition 

St. Anthony, Labrador, 285, 

297-98 
Sand, Rene, 123 



Scarlet fever, 147, 167, 275 

Schedules, typical, 52-54 

School conditions, 66, 86- 
87, 228-40, 244-45, 
271-72 
examinations, 231* 
hours, 234-39 
lunches, 241-48 
program, 153-54, 217*-18, 

235-39, 291* 
See also Open-air schools 

Seasonal growth, see 
Growth, seasonal 

Self-abuse, see Masturba- 
tion 

Setting-up exercises, 145 

Seven per cent underweight 
test, 14, 284-88 

Sex habits, 72-73 

Shoes, 131 

Signs of malnutrition, see 
Malnutrition, signs of 

Sinus infection, 31 

Skilton, Mabel, xiii, xix 

Skin test, see Cutaneous 
proteid test 

Sleep, amount needed, 83, 
168-69 

Sleeping conditions, 55, 56, 
85, 124-25*, 128, 130, 
168, 199-200 

Sleeping out, 124, 139; see 
also Window tent 

Smedley, F. W., 309 

Smoking, 118 

Social examination, 51-59, 
197; see also Case 
history, Home condi- 
tions 

Soup, thin, 93-94*, 278 



340 



INDEX 



"Spoiled child," 46, 73, 75, 

140 
Sports, see Athletics 
Stars, colored, 187 
Stearns, A. Warren, 48, 

332 
Story-telling, 85 
Stunting, 9*-10, 15-16, 70, 

154 
Suggestion, influence of, 70, 

72, 75 
Summer camp, see Camp 

life 
program, 138-39 
Sunlight, 124 
Sweets, 98, 114; see also 

Candy 
Swimming, 132, 247-48, 254 
Syphilis, viii, xii, 6, 16, 22, 

32 
Statistics, see Tables 



Tables, 38, 99, 100-06, 149, 

157, 177, 284-87, 293- 

98, 305-08 
Tea and coffee, 34, 118, 171, 

248 
Teachers, 229 
Teeth, care of, 130 
defects, 31-32, 166 
grinding of, 169 
Temperature, indoor, 125-28 

test, 33 
Ten per cent underweight 

test, 14, 284-88 
Thyroid, 16, 159 
Tonics, 97, 129 
Tonsils, see Adenoids and 

tonsils 



Toronto, Canada, 285 
Training for health, 70-71; 

see also Child's own 

interest 
Tuberculosis, viii, xii, 6, 33, 

126»-27», 166-67, 266- 

72, 280 



Understanding between par- 
ents and children, 71- 
72, 145 

Underweight, habitual, 15 
handicap of, 144 
lowers resistance, 164, 

276 
See also Borderline cases, 
Malnutrition, Seven 
per cent underweight 
test, Stunting, Ten 
per cent underweight 
test, Weight and 
height 

Unhappiness, 57*, 117 



Vacations, 86 f 139 
Vegetables, 109, 112, 176 
Visceroptosis, 28 
Visitors, 196 
Visits to homes, see Home 

visits 
Vitamins, 107-08, 110, 112, 
175-79 
table of, 177-78 



Walking, 136 

Walpole, Mass., xvi, 286, 
298 



341 



INDEX 



Washing down food, 114-15 
Washington, D. C, 287 
Wassermann test, xii, 32, 

330 
Water drinking, 114, 130 
Weighing, 19 
Weight and age, 12 
Weight and height, 13, 20 
Weight chart, vii, 20, 153, 
205, 254 
as test of condition, 152, 

154, 282 
described, 184-86, 319-20 
Weight, ideal, 17 

standards, 12-13, 174-75, 

309 
tables, 13, 305-10 



See also Group gains, In- 
dividual gains, Over- 
weight, Underweight 
Wet feet, 131-32 
Whooping cough, 147, 167 
Williamstown, Mass., 287 
Window tent, xi 
Wood, Mrs. I. C, xv 
Working conditions, 144-45, 

255, 260* 
World War, 4, 15, 123, 135, 

280 
Worry, 117 
Worms, 170 



X-ray test, 33-34, 330 



(l) 



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